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TMSIS Dataguide Medicaid.gov

Version:

3.38.0

COST-SETTLEMENT-PAYMENT

File Segment

File Segment Number

FTX00008

File Name

FTX - FINANCIAL TRANSACTION

Last updated

Data Elements Reference
DE Number System DE Number Data Element Definition Valid Values
FTX279 FTX.008.279 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.). FTX279 Values
FTX280 FTX.008.280 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. FTX280 Values
FTX281 FTX.008.281 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
FTX282 FTX.008.282 ICN-ORIG A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction. N/A
FTX283 FTX.008.283 ICN-ADJ A unique claim/transaction number assigned by the state's payment system that identifies the adjustment claim/transaction for an original item control number. N/A
FTX285 FTX.008.285 ADJUSTMENT-IND Indicates the type of adjustment record. FTX285 Values
FTX286 FTX.008.286 PAYMENT-OR-RECOUPMENT-DATE The date that the payment or recoupment was executed by the payer. N/A
FTX287 FTX.008.287 PAYMENT-OR-RECOUPMENT-AMOUNT The dollar amount being paid to the payee or recouped from the payee for a previous payment. A recoupment should be reported as a negative amount. N/A
FTX288 FTX.008.288 CHECK-EFF-DATE The date a check is issued to the payee. In the case of electronic funds transfer, it is the date the transfer is made. N/A
FTX289 FTX.008.289 CHECK-NUM The check or electronic funds transfer number. N/A
FTX290 FTX.008.290 PAYER-ID This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. N/A
FTX291 FTX.008.291 PAYER-ID-TYPE This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code. FTX291 Values
FTX292 FTX.008.292 PAYER-ID-TYPE-OTHER-TEXT This is a description of what the payer ID represents when the payer ID was reported with a payer type of "Other". N/A
FTX293 FTX.008.293 PAYEE-ID This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. N/A
FTX294 FTX.008.294 PAYEE-ID-TYPE This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID. FTX294 Values
FTX295 FTX.008.295 PAYEE-ID-TYPE-OTHER-TEXT This is a description of what the PAYEE-ID-TYPE represents when the PAYEE-ID-TYPE was reported with a payee ID type of "Other". N/A
FTX296 FTX.008.296 PAYEE-MCR-PLAN-TYPE This describes the type of managed care plan or care coordination model of the payee, when applicable. The valid value code set is comprised of the standard managed care plan type list from the MCR and ELG files and a complementary list of care coordination models. FTX296 Values
FTX297 FTX.008.297 PAYEE-MCR-PLAN-TYPE-OTHER-TEXT This is a description of what type of managed care plan or care coordination model the payee ID was reported with a payee MCR plan or other care coordination model type of "Other". N/A
FTX298 FTX.008.298 PAYEE-TAX-ID This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. N/A
FTX299 FTX.008.299 PAYEE-TAX-ID-TYPE This is a qualifier that indicates what type of tax ID the payee tax ID is. For example, if the payee tax ID represents a SSN, then the payee tax ID type will indicate that the payee tax ID should be interpreted as a SSN. FTX299 Values
FTX300 FTX.008.300 PAYEE-TAX-ID-TYPE-OTHER-TEXT This is a description of what the PAYEE-TAX-ID-TYPE represents when the PAYEE-TAX-ID-TYPE was reported with a payee tax ID type of "Other". N/A
FTX301 FTX.008.301 COST-SETTLEMENT-PERIOD-START-DATE The date representing the beginning of the cost settlement period. For example, if the cost settlement is for the first calendar quarter of the year then the Cost Settlement Period Start Date would be January 1 of that year and the Cost Settlement Period End Date would be March 31 of that year. Likewise, if the cost settlement is for the first calendar month of the year then the Cost Settlement Period Start Date would be January 1 of that year and the Cost Settlement Period End Date would be January 31 of that year. N/A
FTX302 FTX.008.302 COST-SETTLEMENT-PERIOD-END-DATE The date representing the end of the cost-settlement period. For example, if the cost-settlement is for the first calendar quarter of the year, then the cost settlement end date would be March 31 of that year. N/A
FTX303 FTX.008.303 CATEGORY-FOR-FEDERAL-REIMBURSEMENT A code to indicate the Federal funding source for the payment. FTX303 Values
FTX306 FTX.008.306 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)). FTX306 Values
FTX305 FTX.008.305 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. FTX305 Values
FTX304 FTX.008.304 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. FTX304 Values
FTX307 FTX.008.307 WAIVER-ID Field specifying the waiver or demonstration which authorized payment. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments. N/A
FTX308 FTX.008.308 WAIVER-TYPE A code for specifying waiver type under which the eligible individual is covered during the month and receiving services/under which transaction is submitted. FTX308 Values
FTX309 FTX.008.309 FUNDING-CODE A code to indicate the source of non-federal share funds. FTX309 Values
FTX310 FTX.008.310 FUNDING-SOURCE-NONFEDERAL-SHARE A code to indicate the type of non-federal share used by the state to finance its expenditure to the provider. In the event of two sources, states are to report the portion which represents the largest proportion not funded by the Federal government. FTX310 Values
FTX311 FTX.008.311 SOURCE-LOCATION The field denotes the claims/transaction processing system in which the claims/transactions were originally processed. FTX311 Values
FTX312 FTX.008.312 SPA-NUMBER 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. N/A
FTX313 FTX.008.313 EXPENDITURE-AUTHORITY-TYPE Expenditure Authority Type is the federal statute or regulation under which the expenditure is authorized/justified. The federal statute or regulation is usually referenced in either the Medicaid or CHIP State Plan or waiver documentation. For waivers, do not reference the federal statute or regulation being waived by the waiver. For waivers, referring to the waiver authority is sufficient. If the federal statute or regulation is not available in the list of valid values, choose the value for "Other" and report the authority in the Expenditure Authority Type Text. FTX313 Values
FTX314 FTX.008.314 EXPENDITURE-AUTHORITY-TYPE-OTHER-TEXT This field is only to be used if Expenditure Authority Type "Other" valid value is selected. Enter a specific text description of the "Other" expenditure authority type. N/A
FTX315 FTX.008.315 MEMO This represents any notes from the state's ledger/accounting system associated with the payment/recoupment. N/A
FTX316 FTX.008.316 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A
Definition
A record segment to capture cost settlement payments.

File Segment Length
2500