FTX.002.048

MBESCBES-FORM-GROUP

Data Element

DE Number

FTX048

System DE Number

FTX.002.048

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	Indicates group of MBES/CBES forms that this payment applies to (e.g., the CMS-64.9 Base form is for Title XIX-funded Medicaid, the CMS-64.21 form is for Title XXI-funded Medicaid-expansion CHIP (M-CHIP), and the CMS-21 Base form is for Title XXI-funded separate CHIP (S-CHIP)).
Size	X(1)
FLF Start Position	905
FLF Stop Position	905
Segment Key Field Identifier	Not Applicable
Coding Requirements	1. Value must be 1 character 2. Value must be in MBESCBES Form Group List (VVL) 3. Value must be populated when Payer ID Type equals "01" 4. Conditional 5. If Subcapitation Indicator equals "2", then value must not be populated 6. When not populated, an associated MBESCBES Form Group and MBESCBES Form must not be populated

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

RULE ID	RULE Definition
RULE-8046	If a financial transaction is from an FTX file, then the MBESCBES-form-group value reported must be compatible with specified T-MSIS picture format: X(1).
RULE-8413	If the MBESCBES form group is populated on the Individual Capitation PMPM transaction from a FTX file, then the MBESCBES form group reported must be found in the list of valid values.
RULE-8692	If the Individual Capitation Payment segment is populated and transaction is not a sub-capitation payment or recoupment from a FTX file, then the MBESCBES-FORM-GROUP must be populated

Measure ID	Measure Name
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-55-004-4	Health home capitation ratio
MCR-55-003-3	PACE capitation ratio
MCR-55-002-2	Enhanced PCCM capitation ratio
MCR-55-001-1	Traditional PCCM capitation ratio
MCR-54-012-12	# of PCCM plans with at least 100 enrollments, capitations, or encounters, that do not have a managed care record
MCR-54-011-11	# of PCCM plan IDs
MCR-54-010-10	# of plans where MC plan type does not match EL plan type
MCR-54-009-9	# of plans with at least 100 enrollments, capitations, or encounters, that do not have a managed care record
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)
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-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-54-005-5	# of plans with at least 100 capitations or 100 encounters, 0 enrollments
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-54-003-3	# of plans with at least 100 enrollments or 100 encounters, 0 capitations
MCR-54-002-2	# of plans with at least 100 enrollments or 100 capitations, 0 encounters
MCR-54-001-1	# of plans with at least 100 enrollments, 0 capitations, 0 encounters
MCR-53-003-3	Total # of managed care encounters
MCR-53-002-2	Total # of managed care capitations
MCR-53-001-1	Total # of managed care enrollments

DE Number	System DE Number	DE Name	File Segment Number	File Segment Name
CIP340	CIP.003.340	MBESCBES-FORM-GROUP	CIP00003	CLAIM-LINE-RECORD-IP
CLT282	CLT.003.282	MBESCBES-FORM-GROUP	CLT00003	CLAIM-LINE-RECORD-LT
COT290	COT.003.290	MBESCBES-FORM-GROUP	COT00003	CLAIM-LINE-RECORD-OT
CRX209	CRX.003.209	MBESCBES-FORM-GROUP	CRX00003	CLAIM-LINE-RECORD-RX
FTX093	FTX.003.093	MBESCBES-FORM-GROUP	FTX00003	INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX137	FTX.004.137	MBESCBES-FORM-GROUP	FTX00004	GROUP-INSURANCE-PREMIUM-PAYMENT
FTX179	FTX.005.179	MBESCBES-FORM-GROUP	FTX00005	COST-SHARING-OFFSET
FTX221	FTX.006.221	MBESCBES-FORM-GROUP	FTX00006	VALUE-BASED-PAYMENT
FTX266	FTX.007.266	MBESCBES-FORM-GROUP	FTX00007	STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX306	FTX.008.306	MBESCBES-FORM-GROUP	FTX00008	COST-SETTLEMENT-PAYMENT
FTX345	FTX.009.345	MBESCBES-FORM-GROUP	FTX00009	FQHC-WRAP-PAYMENT
FTX393	FTX.095.393	MBESCBES-FORM-GROUP	FTX00095	MISCELLANEOUS-PAYMENT

Published Date	Data Guide Version	Data Element	Action	Field	Before	After
09/25/2025	4.0.18	FTX.002.048	UPDATE	Coding requirement	1. Value must be 1 character2. Value must be in MBESCBES Form Group List (VVL)3. Value must be populated when Payer ID Type equals "01"4. Conditional	1. Value must be 1 character2. Value must be in MBESCBES Form Group List (VVL)3. Value must be populated when Payer ID Type equals "01"4. Conditional5. If Subcapitation Indicator equals "2", then value must not be populated6. When not populated, an associated MBESCBES Form Group and MBESCBES Form must not be populated
02/27/2025	4.0.3	FTX.002.048	UPDATE	Coding requirement	1. Value must be 1 character2. Value must be in MBESCBES Form Group List (VVL)3. If Subcapitation Indicator equals "1", then value must be populated4. Conditional	1. Value must be 1 character2. Value must be in MBESCBES Form Group List (VVL)3. Value must be populated when Payer ID Type equals "01"4. Conditional
12/19/2024	4.0.1	FTX.002.048	UPDATE	Coding requirement	1. Value must be 1 character2. Value must be in MBESCBES Form Group List (VVL)3. If Subcapitation Indicator equals "01", then value must be populated4. Conditional	1. Value must be 1 character2. Value must be in MBESCBES Form Group List (VVL)3. If Subcapitation Indicator equals "1", then value must be populated4. Conditional
09/16/2024	4.0.0	FTX.002.048	UPDATE	File segment	None	68
09/16/2024	4.0.0	FTX.002.048	ADD	N/A		Created