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

MISCELLANEOUS-PAYMENT

File Segment

File Segment Number

FTX00095

File Name

FTX - FINANCIAL TRANSACTION

Last updated

Data Elements Reference
DE Number System DE Number Data Element Definition Valid Values
FTX357 FTX.095.357 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.). FTX357 Values
FTX358 FTX.095.358 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. FTX358 Values
FTX359 FTX.095.359 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
FTX360 FTX.095.360 ICN-ORIG A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction. N/A
FTX361 FTX.095.361 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
FTX363 FTX.095.363 ADJUSTMENT-IND Indicates the type of adjustment record. FTX363 Values
FTX364 FTX.095.364 PAYMENT-OR-RECOUPMENT-DATE The date that the payment or recoupment was executed by the payer. N/A
FTX365 FTX.095.365 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
FTX366 FTX.095.366 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
FTX367 FTX.095.367 CHECK-NUM The check or electronic funds transfer number. N/A
FTX368 FTX.095.368 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
FTX369 FTX.095.369 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. FTX369 Values
FTX370 FTX.095.370 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
FTX371 FTX.095.371 PAYER-MCR-PLAN-TYPE This describes the type of managed care plan or care coordination model of the payer, when applicable. The valid value list is comprised of the standard managed care plan type list from the MCR and ELG files and a complementary list of care coordination models. FTX371 Values
FTX372 FTX.095.372 PAYER-MCR-PLAN-TYPE-OTHER-TEXT This is a description of what type of managed care plan or care coordination model the payer ID was reported with a PAYER-MCR-PLAN-OR-OTHER-TYPE of "Other". N/A
FTX373 FTX.095.373 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
FTX374 FTX.095.374 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. FTX374 Values
FTX375 FTX.095.375 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
FTX376 FTX.095.376 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. FTX376 Values
FTX377 FTX.095.377 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
FTX378 FTX.095.378 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
FTX379 FTX.095.379 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. FTX379 Values
FTX380 FTX.095.380 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
FTX381 FTX.095.381 CONTRACT-ID Managed care plan contract ID N/A
FTX382 FTX.095.382 INSURANCE-CARRIER-ID-NUM The state-assigned identification number of the Third Party Liability (TPL) Entity. N/A
FTX383 FTX.095.383 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
FTX384 FTX.095.384 PAYMENT-PERIOD-START-DATE The date representing the start of the time period that the payment is expected to be used by the provider. N/A
FTX385 FTX.095.385 PAYMENT-PERIOD-END-DATE The date representing the end of the time period that the payment is expected to be used by the provider. N/A
FTX386 FTX.095.386 PAYMENT-PERIOD-TYPE A qualifier that identifies what the payment period begin and end dates represent. For example, the payment period begin an end dates may correspond to a range of service dates from claims or encounters or they may represent a period of beneficiary eligibility or enrollment. FTX386 Values
FTX387 FTX.095.387 PAYMENT-PERIOD-TYPE-OTHER-TEXT This is a description of the type of financial transaction when the PAYMENT-PERIOD-TYPE is "Other". N/A
FTX388 FTX.095.388 TRANSACTION-TYPE This is a code that classifies the type of financial transaction when the financial transaction does not fit into any other financial transaction segment type (e.g., FTX00002, FTX00003, FTX00004, etc.). FTX388 Values
FTX389 FTX.095.389 TRANSACTION-TYPE-OTHER-TEXT This is a description of the type of financial transaction when the TRANSACTION-TYPE is "Other". N/A
FTX390 FTX.095.390 CATEGORY-FOR-FEDERAL-REIMBURSEMENT A code to indicate the Federal funding source for the payment. FTX390 Values
FTX393 FTX.095.393 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)). FTX393 Values
FTX392 FTX.095.392 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. FTX392 Values
FTX391 FTX.095.391 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. FTX391 Values
FTX394 FTX.095.394 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
FTX395 FTX.095.395 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. FTX395 Values
FTX396 FTX.095.396 FUNDING-CODE A code to indicate the source of non-federal share funds. FTX396 Values
FTX397 FTX.095.397 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. FTX397 Values
FTX398 FTX.095.398 SDP-IND Indicates whether the financial transaction from an MC plan to a provider or other entity is a type of State Directed Payment. FTX398 Values
FTX399 FTX.095.399 SOURCE-LOCATION The field denotes the claims/transaction processing system in which the claims/transactions were originally processed. FTX399 Values
FTX400 FTX.095.400 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
FTX401 FTX.095.401 PAYMENT-CAT-XREF Cross-reference to the applicable payment category in the managed care plan's contract with the state Medicaid/CHIP agency or their fiscal intermediary. N/A
FTX402 FTX.095.402 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. FTX402 Values
FTX403 FTX.095.403 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
FTX404 FTX.095.404 MEMO This represents any notes from the state's ledger/accounting system associated with the payment/recoupment. N/A
FTX405 FTX.095.405 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A
Definition
A record segment to capture any other miscellaneous payment transaction that is not explicitly excluded from T-MSIS reporting or does not meet the definition of and was therefore not mapped to any other specific transaction type must be reported to this financial transaction segment type.

File Segment Length
2500