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Data Element
FTX068
FTX.003.068
Definition | A unique claim/transaction number assigned by the state's payment system that identifies the adjustment claim/transaction for an original item control number. |
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Size | X(50) |
FLF Start Position | 72 |
FLF Stop Position | 121 |
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 is in [4,1], then value must be populated |
Valid Value Code Set | Valid Value Code | Valid Value Name | Valid Value Description | Effective Start Date | Effective End Date |
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DE Number | System DE Number | DE Name | File Segment Number | File Segment Name |
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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 |
CRX113 | CRX.003.113 | ICN-ADJ | CRX00003 | CLAIM-LINE-RECORD-RX |
CRX200 | CRX.004.200 | ICN-ADJ | CRX00004 | CLAIM-DX-RX |
FTX021 | FTX.002.021 | ICN-ADJ | FTX00002 | INDIVIDUAL-CAPITATION-PMPM |
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 |