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Data Element
FTX099
FTX.003.099
Definition | State plan amendment (SPA) ID number using the following format: SS-YY-NNNN-xxxx where: SS = State (use the two character postal abbreviation for your state); YY = Calendar Year (last two characters of the calendar year of the state plan amendment); NNNN = SPA number (a four character number beginning with 0001) States should track their submissions to assign sequential numbers to their submissions. xxxx = Optional, 1 to 4 characters alpha/numeric modifier (Suffix) States should use the specific SPA that covered the services rendered. |
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Size | X(15) |
FLF Start Position | 737 |
FLF Stop Position | 751 |
Segment Key Field Identifier | Not Applicable |
Coding Requirements | 1. Value must be 15 characters or less 2. Conditional |
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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FTX055 | FTX.002.055 | SPA-NUMBER | FTX00002 | INDIVIDUAL-CAPITATION-PMPM |
FTX143 | FTX.004.143 | SPA-NUMBER | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT |
FTX186 | FTX.005.186 | SPA-NUMBER | FTX00005 | COST-SHARING-OFFSET |
FTX228 | FTX.006.228 | SPA-NUMBER | FTX00006 | VALUE-BASED-PAYMENT |
FTX272 | FTX.007.272 | SPA-NUMBER | FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM |
FTX312 | FTX.008.312 | SPA-NUMBER | FTX00008 | COST-SETTLEMENT-PAYMENT |
FTX351 | FTX.009.351 | SPA-NUMBER | FTX00009 | FQHC-WRAP-PAYMENT |
FTX400 | FTX.095.400 | SPA-NUMBER | FTX00095 | MISCELLANEOUS-PAYMENT |