| CRX108 |
CRX.003.108
|
RECORD-ID |
The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). |
CRX108 Values
|
| CRX109 |
CRX.003.109
|
SUBMITTING-STATE |
A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. |
CRX109 Values
|
| CRX110 |
CRX.003.110
|
RECORD-NUMBER |
A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. |
N/A
|
| CRX111 |
CRX.003.111
|
MSIS-IDENTIFICATION-NUM |
A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number.
https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ |
N/A
|
| CRX112 |
CRX.003.112
|
ICN-ORIG |
A unique number assigned by the state's payment system that identifies an original or adjustment claim. |
N/A
|
| CRX113 |
CRX.003.113
|
ICN-ADJ |
A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction. |
N/A
|
| CRX114 |
CRX.003.114
|
LINE-NUM-ORIG |
A unique number to identify the transaction line number that is being reported on the original claim. |
N/A
|
| CRX115 |
CRX.003.115
|
LINE-NUM-ADJ |
A unique number to identify the transaction line number that identifies the line number on the adjustment claim. |
N/A
|
| CRX116 |
CRX.003.116
|
LINE-ADJUSTMENT-IND |
A code to indicate the type of adjustment record claim/encounter represents at claim detail level. |
CRX116 Values
|
| CRX117 |
CRX.003.117
|
LINE-ADJUSTMENT-REASON-CODE |
Claim adjustment reason codes communicate why a service line was paid differently than it was billed. |
CRX117 Values
|
| CRX118 |
CRX.003.118
|
SUBMITTER-ID |
The Submitter Identification number is the value that identifies the provider/trading partner/clearing house organization to the state's claim adjudication system. |
N/A
|
| CRX119 |
CRX.003.119
|
CLAIM-LINE-STATUS |
The claim line status codes from the 277 transaction set identify the status of a specific detail claim line rather than the entire claim. Only report the claim line for the final, adjudicated claim. |
CRX119 Values
|
| CRX120 |
CRX.003.120
|
NATIONAL-DRUG-CODE |
A code following the National Drug Code format indicating the drug, device, or medical supply covered by this claim. |
N/A
|
| CRX121 |
CRX.003.121
|
BILLED-AMT |
The amount billed at the claim detail level as submitted by the provider. For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed the managed care plan. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the provider billed the sub-capitated entity at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.
For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
N/A
|
| CRX122 |
CRX.003.122
|
ALLOWED-AMT |
The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed care encounters the Allowed Amount is determined by the managed care organization. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity allowed at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.
For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
N/A
|
| CRX123 |
CRX.003.123
|
BENEFICIARY-COPAYMENT-PAID-AMOUNT |
The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on a claim line. Do not include copayment payments made by a third party/ies on behalf of the beneficiary. This is a copayment paid for a service in the corresponding claim line for OT and RX claim files. The Beneficiary Copayment Paid Amount is an optional line level data element reported for OT and RX claim file types, only. If the beneficiary copayment paid amount is not available at the claim line level, report the total copayment paid amount in the header level copayment data element. |
N/A
|
| CRX124 |
CRX.003.124
|
TPL-AMT |
Third-party liability refers to the legal obligation of third parties, i.e., certain individuals, entities, or programs, to pay all or part of the expenditures for medical assistance furnished under a state plan. This is the total amount denoted at the claim detail level paid by the third party. |
N/A
|
| CRX125 |
CRX.003.125
|
MEDICAID-PAID-AMT |
The amount paid to the provider by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.
For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
N/A
|
| CRX126 |
CRX.003.126
|
MEDICAID-FFS-EQUIVALENT-AMT |
The amount that would have been paid had the services been provided on a Fee for Service basis. |
N/A
|
| CRX127 |
CRX.003.127
|
MEDICARE-DEDUCTIBLE-AMT |
The amount paid by Medicaid/CHIP on this claim at the claim line level toward the beneficiary's Medicare deductible. If the Medicare deductible amount can be identified separately from Medicare coinsurance payments, code that amount in this field. If the Medicare coinsurance and deductible payments cannot be separated, fill this field with the combined payment amount and Medicare Coinsurance Payment is not required. |
N/A
|
| CRX128 |
CRX.003.128
|
MEDICARE-COINS-AMT |
The amount paid by Medicaid/CHIP on this claim toward the recipient's Medicare coinsurance at the claim detail level. If the Medicare coinsurance amount can be identified separately from Medicare deductible payments, code that amount in this field. If Medicare coinsurance and deductible payments cannot be separated, populate the Medicare Deductible Amount. |
N/A
|
| CRX129 |
CRX.003.129
|
MEDICARE-PAID-AMT |
The amount paid by Medicare on this claim. For claims where Medicare payment is only available at the header level, report the entire payment amount on the T-MSIS claim line with the highest charge or the 1st non-denied line. Zero fill Medicare Paid Amount on all other claim lines. |
N/A
|
| CRX131 |
CRX.003.131
|
PRESCRIPTION-QUANTITY-ALLOWED |
The maximum allowable quantity of a drug or service that may be dispensed per prescription per date of service or per month. Quantity limits are applied to medications when the majority of appropriate clinical utilizations will be addressed within the quantity allowed. For use with CLAIMRX claims/encounters. For CLAIMOT claims/encounter records, use the Service Quantity Allowed field. For CLAIMIP and CLAIMLT claims/encounter records, use the Revenue Center Quantity Allowed field. One prescription for 100 250 milligram tablets results in Prescription Quantity Allowed =100. |
N/A
|
| CRX132 |
CRX.003.132
|
PRESCRIPTION-QUANTITY-ACTUAL |
The quantity of a drug that is dispensed for a prescription as reported ny National Drug Code on the claim line. For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMLT claims/encounter records, use the Revenue Center Quantity Actual field. |
N/A
|
| CRX133 |
CRX.003.133
|
UNIT-OF-MEASURE |
A code to indicate the basis by which the quantity of the drug or supply is expressed. |
CRX133 Values
|
| CRX134 |
CRX.003.134
|
TYPE-OF-SERVICE |
A code to categorize the services provided to a Medicaid or CHIP enrollee. |
CRX134 Values
|
| CRX135 |
CRX.003.135
|
HCBS-SERVICE-CODE |
A code to indicate that the service represents a long-term care home and community based service or support for an individual with chronic medical and/or mental conditions. The codes help to delineate between acute care and long-term care provided in the home and community setting (e.g. 1915(c), 1915(i), 1915(j), and 1915(k) services). |
CRX135 Values
|
| CRX136 |
CRX.003.136
|
HCBS-TAXONOMY |
A code to classify the home and community based services listed on the claim into the HCBS taxonomy. The HCBS Taxonomic classification system was adopted by CMS in August 2012.
To acknowledge state variation, services and categories are defined based on the minimum definition necessary to establish mutually distinct categories and services. Some services are defined in part by characteristics that are NOT in that service. For example, the difference between companion services and personal care is that companion services do not include assistance with activities of daily living (ADLs) such as bathing, dressing, eating, and toileting.
Some of the services reflected by the HCBS Taxonomy including, but not limited to personal care, case management, home health aide, and physician services, may (and in some case, must) also be covered under the Medicaid State Plan. The definitions below only define these services for purposes of Section 1915(c) Waivers and the State Plan Home and Community-Based Services benefit authorized by Section 1915(i). States interested in reflecting services as 'extended state plan' services must offer them in accordance with state plan service definitions. Consult with the CMS Division of Benefits and Coverage in those instances to ensure definition alignment.
The services and categories are arranged in order of consideration for placing a particular state service in the taxonomy. If one is not sure how to map a state's service to the taxonomy, one should first consider Case Management, then Round-the-Clock Services, then Supported Employment, etc.
Documentation of the HCBS Taxonomy from the CMS Waiver Management System can be found here: https://wms-mmdl.cms.gov/WMS/help/TaxonomyCategoryDefinitions.pdf |
CRX136 Values
|
| CRX137 |
CRX.003.137
|
OTHER-TPL-COLLECTION |
This data element indicates that the claim is for a beneficiary for whom other third party resource development and collection activities are in progress, when the liability is not another health insurance plan for which the eligible is a beneficiary. |
CRX137 Values
|
| CRX138 |
CRX.003.138
|
DAYS-SUPPLY |
Number of days supply dispensed. |
N/A
|
| CRX139 |
CRX.003.139
|
NEW-REFILL-IND |
Indicator showing whether the prescription being filled was a new prescription or a refill. If it is a refill, the indicator will indicate the number of refills. |
CRX139 Values
|
| CRX140 |
CRX.003.140
|
BRAND-GENERIC-IND |
Indicates whether the drug is a brand name, generic, single-source, or multi-source drug. |
CRX140 Values
|
| CRX141 |
CRX.003.141
|
DISPENSE-FEE-SUBMITTED |
The charge to cover the cost of the professional dispensing fee for the prescription. |
N/A
|
| CRX142 |
CRX.003.142
|
PRESCRIPTION-NUM |
The unique identification number assigned by the pharmacy or supplier to the prescription. |
N/A
|
| CRX143 |
CRX.003.143
|
DRUG-UTILIZATION-CODE |
A code indicating the conflict, intervention and outcome of a prescription presented for fulfillment. The T-MSIS Drug Utilization Code data element is composite field comprised of three distinct NCPDP data elements: 'Reason for Service Code' (439-E4); 'Professional Service Code' (440-E5); and 'Result of Service Code' (441-E6). All 3 of these NCPDP fields are situationally required and independent of one another. Pharmacists may report none, one, two or all three. NCPDP situational rules call for one or more of these values in situations where the field(s) could result in different coverage, pricing, patient financial responsibility, drug utilization review outcome, or if the information affects payment for, or documentation of, professional pharmacy service. The NCPDP 'Reasons of Service Code' (bytes 1 & 2 of the T-MSIS DRUG-UTILIZATION-CODE) explains whether the pharmacist filled the prescription, filled part of the prescription, etc. The NCPDP 'Professional Service Code' (bytes 3 & 4 of the T-MSIS Drug Utilization Code) describes what the pharmacist did for the patient. The NCPDP 'Result of Service Code' (bytes 5 & 6 of the T-MSIS Drug Utilization Code) describes the action the pharmacist took in response to a conflict or the result of a pharmacist's professional service. Because the T-MSIS Drug Utilization Code data element is a composite field, it is necessary for the state to populate all six bytes if any of the three NCPDP fields has a value. In such situations, use 'spaces' as placeholders for not applicable codes. |
CRX143 Values
|
| CRX144 |
CRX.003.144
|
DTL-METRIC-DEC-QTY |
Metric decimal quantity of the product with the appropriate unit of measure (each, gram, or milliliter). |
N/A
|
| CRX145 |
CRX.003.145
|
COMPOUND-DOSAGE-FORM |
The physical form of a dose of medication, such as a capsule or injection. |
CRX145 Values
|
| CRX146 |
CRX.003.146
|
REBATE-ELIGIBLE-INDICATOR |
An indicator to identify claim lines with an NDC that is eligible for the drug rebate program. |
CRX146 Values
|
| CRX149 |
CRX.003.149
|
CATEGORY-FOR-FEDERAL-REIMBURSEMENT |
A code to indicate the Federal funding source for the payment. |
CRX149 Values
|
| CRX152 |
CRX.003.152
|
OTHER-INSURANCE-AMT |
The amount paid by insurance other than Medicare or Medicaid on this claim. |
N/A
|
| CRX157 |
CRX.003.157
|
ADJUDICATION-DATE |
The date on which the payment status of the claim was finally adjudicated by the state. For Encounter Records (Type of Claim = 3, C, W), use date the encounter was processed by the state. |
N/A
|
| CRX158 |
CRX.003.158
|
SELF-DIRECTION-TYPE |
This data element is not applicable to this file type. |
CRX158 Values
|
| CRX159 |
CRX.003.159
|
PRE-AUTHORIZATION-NUM |
A number, code or other value that indicates the services provided on this claim have been authorized by the payee or other service organization, or that a referral for services has been approved. (Also referred to as a Prior Authorization or Referral Number). |
N/A
|
| CRX167 |
CRX.003.167
|
INGREDIENT-COST-SUBMITTED |
The charge to cover the cost of ingredients for the prescription or drug. |
N/A
|
| CRX168 |
CRX.003.168
|
INGREDIENT-COST-PAID-AMT |
The amount paid by Medicaid or the managed care plan on this claim or adjustment at the claim detail level towards the cost of ingredients for the prescription or drug. |
N/A
|
| CRX169 |
CRX.003.169
|
DISPENSE-FEE-PAID-AMT |
The amount paid by Medicaid or the managed care plan on this claim or adjustment towards the cost of the pharmacy's professional dispensing fee for the prescription. |
N/A
|
| CRX170 |
CRX.003.170
|
PROFESSIONAL-SERVICE-FEE-SUBMITTED |
The charge to cover the clinical services, not otherwise covered under the professional dispensing fee. (Example - not filling a prescription because of therapeutic duplication). |
N/A
|
| CRX171 |
CRX.003.171
|
PROFESSIONAL-SERVICE-FEE-PAID-AMT |
The amount paid by Medicaid or the managed care plan on this claim or adjustment towards the costs of clinical services not otherwise covered under the professional dispensing fee. |
N/A
|
| CRX172 |
CRX.003.172
|
IHS-SERVICE-IND |
To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. |
CRX172 Values
|
| CRX179 |
CRX.003.179
|
UNIQUE-DEVICE-IDENTIFIER |
An unique identifier assigned to every medical device that meets the requirements of 21 CFR 801 and 830. |
N/A
|
| CRX209 |
CRX.003.209
|
MBESCBES-FORM-GROUP |
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)). |
CRX209 Values
|
| CRX181 |
CRX.003.181
|
MBESCBES-FORM |
The MBES or CBES form to which the expenditure will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is. |
CRX181 Values
|
| CRX180 |
CRX.003.180
|
MBESCBES-CATEGORY-OF-SERVICE |
A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.) that states use to report their expenditures and request federal financial participation. |
CRX180 Values
|
| CRX182 |
CRX.003.182
|
PROCEDURE-CODE |
The procedure code (e.g., CPT, HCPCS, or other procedure code that is not an NDC or UDI) reported by a pharmacy on their NCPDP transaction. |
CRX182 Values
|
| CRX183 |
CRX.003.183
|
PROCEDURE-CODE-MOD-1 |
The first modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier). |
CRX183 Values
|
| CRX184 |
CRX.003.184
|
PROCEDURE-CODE-MOD-2 |
The second modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier). |
CRX184 Values
|
| CRX185 |
CRX.003.185
|
PROCEDURE-CODE-MOD-3 |
The third modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier). |
CRX185 Values
|
| CRX186 |
CRX.003.186
|
PROCEDURE-CODE-MOD-4 |
The fourth modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier). |
CRX186 Values
|
| CRX187 |
CRX.003.187
|
PROCEDURE-CODE-MOD-5 |
The fifth modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier). |
CRX187 Values
|
| CRX188 |
CRX.003.188
|
PROCEDURE-CODE-MOD-6 |
The sixth modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier). |
CRX188 Values
|
| CRX189 |
CRX.003.189
|
PROCEDURE-CODE-MOD-7 |
The seventh modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier). |
CRX189 Values
|
| CRX190 |
CRX.003.190
|
PROCEDURE-CODE-MOD-8 |
The eighth modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier). |
CRX190 Values
|
| CRX191 |
CRX.003.191
|
PROCEDURE-CODE-MOD-9 |
The ninth modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier). |
CRX191 Values
|
| CRX192 |
CRX.003.192
|
PROCEDURE-CODE-MOD-10 |
The tenth modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier). |
CRX192 Values
|
| CRX193 |
CRX.003.193
|
GME-AMOUNT-PAID |
The amount included in the Medicaid Amount (CRX.003.125) that is attributable to a Graduate Medical Education (GME) payment, when the state makes GME payments by claim. |
N/A
|
| CRX194 |
CRX.003.194
|
SDP-ALLOWED-AMT |
The component (in dollar and cents) of the allowed amount that represents the difference between what would have been the managed care plan's typical contractual allowed amount and the enhanced allowed amount for this specific claim as defined by the State's SPA, waiver, or demonstration for a State Directed Payment model per 42 CFR 438.6(c)(1)(iii). |
N/A
|
| CRX195 |
CRX.003.195
|
SDP-PAID-AMT |
The component (in dollar and cents) of the paid amount that represents the difference between what would have been the managed care plan's typical contractual paid amount and the enhanced paid amount for this specific claim as defined by the State's SPA, waiver, or demonstration for a State Directed Payment model per 42 CFR 438.6(c)(1)(iii). |
N/A
|
| CRX153 |
CRX.003.153
|
STATE-NOTATION |
A free text field for the submitting state to enter whatever information it chooses. |
N/A
|
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