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TMSIS Dataguide Medicaid.gov

Version:

3.38.0

MBESCBES-FORM-GROUP

Data Element

DE Number

FTX093

System DE Number

FTX.003.093

File Name

FTX - FINANCIAL TRANSACTION

File Segment Number

FTX00003

File Segment Name

INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT

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 653
FLF Stop Position 653
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. Mandatory
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
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
FTX048 FTX.002.048 MBESCBES-FORM-GROUP FTX00002 INDIVIDUAL-CAPITATION-PMPM
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