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TMSIS Dataguide Medicaid.gov

Version:

3.38.0

COST-SHARING-OFFSET

File Segment

File Segment Number

FTX00005

File Name

FTX - FINANCIAL TRANSACTION

Last updated

Data Elements Reference
DE Number System DE Number Data Element Definition Valid Values
FTX149 FTX.005.149 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.). FTX149 Values
FTX150 FTX.005.150 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. FTX150 Values
FTX151 FTX.005.151 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
FTX152 FTX.005.152 ICN-ORIG A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction. N/A
FTX153 FTX.005.153 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
FTX155 FTX.005.155 ADJUSTMENT-IND Indicates the type of adjustment record. FTX155 Values
FTX156 FTX.005.156 PAYMENT-OR-RECOUPMENT-DATE The date that the payment or recoupment was executed by the payer. N/A
FTX157 FTX.005.157 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
FTX158 FTX.005.158 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
FTX159 FTX.005.159 CHECK-NUM The check or electronic funds transfer number. N/A
FTX160 FTX.005.160 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. For beneficiary Cost Sharing Offset, the payer is always the state and the payee is always a beneficiary. N/A
FTX161 FTX.005.161 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. FTX161 Values
FTX162 FTX.005.162 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
FTX163 FTX.005.163 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. For beneficiary Cost Sharing Offset, the beneficiary is always the payee. N/A
FTX164 FTX.005.164 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. FTX164 Values
FTX165 FTX.005.165 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
FTX166 FTX.005.166 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. FTX166 Values
FTX167 FTX.005.167 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
FTX168 FTX.005.168 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
FTX169 FTX.005.169 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. FTX169 Values
FTX170 FTX.005.170 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
FTX171 FTX.005.171 CONTRACT-ID Managed care plan contract ID N/A
FTX172 FTX.005.172 INSURANCE-PLAN-ID The ID number issued by the Insurance carrier providing third party liability insurance coverage to beneficiaries. Typically the Plan ID/Plan Number is on the beneficiaries' insurance card. N/A
FTX173 FTX.005.173 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
FTX174 FTX.005.174 COVERAGE-PERIOD-START-DATE The date representing the beginning of the period covered by the capitation payment or premium payment that the beneficiary is offsetting; for example, the first day of the calendar month of beneficiary enrollment in the managed care plan to which the off-setting amount is applied. If returning money to the beneficiary, this is the date representing the beginning of the period for which the beneficiary had previously made an offsetting payment that is now being returned to them. N/A
FTX175 FTX.005.175 COVERAGE-PERIOD-END-DATE The date representing the end of the period covered by the capitation payment or premium payment that the beneficiary is offsetting; for example, the last day of the calendar month of beneficiary enrollment in the managed care plan to which the off-setting amount is applied. If returning money to the beneficiary, this is the date representing the end of the period for which the beneficiary had previously made an offsetting payment that is now being returned to them. N/A
FTX176 FTX.005.176 CATEGORY-FOR-FEDERAL-REIMBURSEMENT A code to indicate the Federal funding source for the payment. FTX176 Values
FTX179 FTX.005.179 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)). FTX179 Values
FTX178 FTX.005.178 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. FTX178 Values
FTX177 FTX.005.177 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. FTX177 Values
FTX180 FTX.005.180 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
FTX181 FTX.005.181 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. FTX181 Values
FTX182 FTX.005.182 FUNDING-CODE A code to indicate the source of non-federal share funds. FTX182 Values
FTX183 FTX.005.183 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. FTX183 Values
FTX184 FTX.005.184 OFFSET-TRANS-TYPE This indicates the type of payment that the beneficiary cost-sharing is/was offsetting. FTX184 Values
FTX185 FTX.005.185 SOURCE-LOCATION The field denotes the claims/transaction processing system in which the claims/transactions were originally processed. FTX185 Values
FTX186 FTX.005.186 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
FTX187 FTX.005.187 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. FTX187 Values
FTX188 FTX.005.188 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
FTX189 FTX.005.189 MEMO This represents any notes from the state's ledger/accounting system associated with the payment/recoupment. N/A
FTX190 FTX.005.190 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 sharing offsets.

File Segment Length
2500