An official website of the United States government

Official websites use .gov
A .gov website belongs to an official government organization in the United States.

Secure .gov websites use HTTPS
A lock () or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites.

TMSIS Dataguide Medicaid.gov

Version:

3.38.0

FQHC-WRAP-PAYMENT

File Segment

File Segment Number

FTX00009

File Name

FTX - FINANCIAL TRANSACTION

Last updated

Data Elements Reference
DE Number System DE Number Data Element Definition Valid Values
FTX318 FTX.009.318 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.). FTX318 Values
FTX319 FTX.009.319 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. FTX319 Values
FTX320 FTX.009.320 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
FTX321 FTX.009.321 ICN-ORIG A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction. N/A
FTX322 FTX.009.322 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
FTX324 FTX.009.324 ADJUSTMENT-IND Indicates the type of adjustment record. FTX324 Values
FTX325 FTX.009.325 PAYMENT-OR-RECOUPMENT-DATE The date that the payment or recoupment was executed by the payer. N/A
FTX326 FTX.009.326 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
FTX327 FTX.009.327 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
FTX328 FTX.009.328 CHECK-NUM The check or electronic funds transfer number. N/A
FTX329 FTX.009.329 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
FTX330 FTX.009.330 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. FTX330 Values
FTX331 FTX.009.331 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
FTX332 FTX.009.332 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
FTX333 FTX.009.333 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. FTX333 Values
FTX334 FTX.009.334 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
FTX335 FTX.009.335 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. FTX335 Values
FTX336 FTX.009.336 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
FTX337 FTX.009.337 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
FTX338 FTX.009.338 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. FTX338 Values
FTX339 FTX.009.339 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
FTX340 FTX.009.340 WRAP-PERIOD-START-DATE The date representing the beginning of the FQHC wrap payment or recoupment period. For example, if the FQHC wrap payment is for the first calendar quarter of the year then the Wrap Period Start Date would be January 1 of that year and the Wrap Period End Date would be March 31 of that year. Likewise, if the FQHC wrap payment is for the first calendar month of the year then the Wrap Period Start Date would be January 1 of that year and the Wrap Period End Date would be January 31 of that year. N/A
FTX341 FTX.009.341 WRAP-PERIOD-END-DATE The date representing the end of the FQHC wrap payment period. For example, if the FQHC wrap payment is for the first calendar quarter of the year, then the FQHC wrap payment end date would be March 31 of that year. N/A
FTX342 FTX.009.342 CATEGORY-FOR-FEDERAL-REIMBURSEMENT A code to indicate the Federal funding source for the payment. FTX342 Values
FTX345 FTX.009.345 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)). FTX345 Values
FTX344 FTX.009.344 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. FTX344 Values
FTX343 FTX.009.343 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. FTX343 Values
FTX346 FTX.009.346 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
FTX347 FTX.009.347 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. FTX347 Values
FTX348 FTX.009.348 FUNDING-CODE A code to indicate the source of non-federal share funds. FTX348 Values
FTX349 FTX.009.349 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. FTX349 Values
FTX350 FTX.009.350 SOURCE-LOCATION The field denotes the claims/transaction processing system in which the claims/transactions were originally processed. FTX350 Values
FTX351 FTX.009.351 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
FTX352 FTX.009.352 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. FTX352 Values
FTX353 FTX.009.353 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
FTX354 FTX.009.354 MEMO This represents any notes from the state's ledger/accounting system associated with the payment/recoupment. N/A
FTX355 FTX.009.355 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A
Definition
A record segment to capture FQHC wrap payments.

File Segment Length
2500