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TMSIS Dataguide Medicaid.gov

Version:

3.38.0

GROUP-INSURANCE-PREMIUM-PAYMENT

File Segment

File Segment Number

FTX00004

File Name

FTX - FINANCIAL TRANSACTION

Last updated

Data Elements Reference
DE Number System DE Number Data Element Definition Valid Values
FTX105 FTX.004.105 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.). FTX105 Values
FTX106 FTX.004.106 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. FTX106 Values
FTX107 FTX.004.107 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
FTX108 FTX.004.108 ICN-ORIG A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction. N/A
FTX109 FTX.004.109 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
FTX111 FTX.004.111 ADJUSTMENT-IND Indicates the type of adjustment record. FTX111 Values
FTX112 FTX.004.112 PAYMENT-DATE The date that the payment was executed by the payer. N/A
FTX113 FTX.004.113 PAYMENT-AMOUNT The dollar amount being paid to the payee. N/A
FTX114 FTX.004.114 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
FTX115 FTX.004.115 CHECK-NUM The check or electronic funds transfer number. N/A
FTX116 FTX.004.116 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 making a payment, as opposed to the payee who is the object of the transaction. The payer is the entity that is making a payment. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. This will typically correspond to the X12 820 Premium Payer. N/A
FTX117 FTX.004.117 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. FTX117 Values
FTX118 FTX.004.118 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
FTX119 FTX.004.119 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 receiving a payment. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of making a payment. This will typically correspond to the X12 820 Premium Receiver. N/A
FTX120 FTX.004.120 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. FTX120 Values
FTX121 FTX.004.121 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
FTX122 FTX.004.122 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 receiving a payment. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of making a payment. This will typically belong to the entity identified as the X12 820 Premium Receiver. N/A
FTX123 FTX.004.123 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. FTX123 Values
FTX124 FTX.004.124 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
FTX125 FTX.004.125 INSURANCE-CARRIER-ID-NUM The state-assigned identification number of the Third Party Liability (TPL) Entity. N/A
FTX126 FTX.004.126 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
FTX127 FTX.004.127 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/ MSIS-IDENTIFICATION-NUM is conditional in the FTX00004 segment because some members of a private group policy may not be eligible for Medicaid or CHIP, though at least one member of the group policy must be eligible for Medicaid or CHIP. There should be one FTX00004 segment for each member of the group policy for which the premium assistance payment is being paid, regardless of whether the member of the group policy was eligible for and enrolled in Medicaid or CHIP. N/A
FTX128 FTX.004.128 SSN The SSN of the member of the group insurance policy. Each FTX00004 segment represents a different member of a given group insurance policy. Typically all members of the group insurance policy will have both an MSIS ID and an SSN. Under some circumstances, it's possible that or more members of a group insurance policy do not have an MSIS ID, but do have an SSN, if they are included on the group insurance policy but not eligible for Medicaid or CHIP. It�s also possible that one or more members of a group insurance policy do not have an SSN. If a member of a group insurance policy does not have an SSN, leave this field blank. N/A
FTX129 FTX.004.129 MEMBER-ID Member identification number as it appears on the card issued by the TPL insurance carrier. N/A
FTX130 FTX.004.130 GROUP-NUM The group number of the TPL health insurance policy. N/A
FTX131 FTX.004.131 POLICY-OWNER-CODE This code identifies the relationship of the policy holder to the Medicaid/CHIP beneficiary. FTX131 Values
FTX132 FTX.004.132 PREMIUM-PERIOD-START-DATE The date representing the beginning of the period covered by the premium payment; for example, the first day of the calendar month of beneficiary coverage in the insurance plan that the payment is intended to cover (whether or not the beneficiary actually receives services during that month). N/A
FTX133 FTX.004.133 PREMIUM-PERIOD-END-DATE The date representing the end of the period covered by the premium payment; for example, the last day of the calendar month of beneficiary coverage in the insurance plan that the payment is intended to cover (whether or not the beneficiary actually receives services during that month). N/A
FTX134 FTX.004.134 CATEGORY-FOR-FEDERAL-REIMBURSEMENT A code to indicate the Federal funding source for the payment. FTX134 Values
FTX137 FTX.004.137 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)). FTX137 Values
FTX136 FTX.004.136 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. FTX136 Values
FTX135 FTX.004.135 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. FTX135 Values
FTX138 FTX.004.138 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
FTX139 FTX.004.139 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. FTX139 Values
FTX140 FTX.004.140 FUNDING-CODE A code to indicate the source of non-federal share funds. FTX140 Values
FTX141 FTX.004.141 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. FTX141 Values
FTX142 FTX.004.142 SOURCE-LOCATION The field denotes the claims/transaction processing system in which the claims/transactions were originally processed. FTX142 Values
FTX143 FTX.004.143 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
FTX144 FTX.004.144 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. FTX144 Values
FTX145 FTX.004.145 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
FTX146 FTX.004.146 MEMO This represents any notes from the state's ledger/accounting system associated with the payment. N/A
FTX147 FTX.004.147 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A
Definition
A record segment to capture group insurance premium payments made by Medicaid or CHIP.

File Segment Length
2500