STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM

File Segment

File Segment Number

FTX00007

File Name

Last updated

Data Elements Reference

DE Number	System DE Number	Data Element	Definition	Valid Values
FTX236	FTX.007.236	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.).	FTX236 Values
FTX237	FTX.007.237	SUBMITTING-STATE	A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received.	FTX237 Values
FTX238	FTX.007.238	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
FTX239	FTX.007.239	ICN-ORIG	A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction.	N/A
FTX240	FTX.007.240	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
FTX242	FTX.007.242	ADJUSTMENT-IND	Indicates the type of adjustment record.	FTX242 Values
FTX243	FTX.007.243	PAYMENT-OR-RECOUPMENT-DATE	The date that the payment or recoupment was executed by the payer.	N/A
FTX244	FTX.007.244	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
FTX245	FTX.007.245	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
FTX246	FTX.007.246	CHECK-NUM	The check or electronic funds transfer number.	N/A
FTX247	FTX.007.247	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
FTX248	FTX.007.248	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.	FTX248 Values
FTX249	FTX.007.249	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
FTX250	FTX.007.250	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
FTX251	FTX.007.251	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.	FTX251 Values
FTX252	FTX.007.252	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
FTX253	FTX.007.253	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.	FTX253 Values
FTX254	FTX.007.254	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
FTX255	FTX.007.255	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
FTX256	FTX.007.256	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.	FTX256 Values
FTX257	FTX.007.257	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
FTX258	FTX.007.258	CONTRACT-ID	Managed care plan contract ID	N/A
FTX259	FTX.007.259	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
FTX260	FTX.007.260	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
FTX261	FTX.007.261	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.	FTX261 Values
FTX262	FTX.007.262	PAYMENT-PERIOD-TYPE-OTHER-TEXT	This is a description of the type of financial transaction when the PAYMENT-PERIOD-TYPE is "Other".	N/A
FTX263	FTX.007.263	CATEGORY-FOR-FEDERAL-REIMBURSEMENT	A code to indicate the Federal funding source for the payment.	FTX263 Values
FTX266	FTX.007.266	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)).	FTX266 Values
FTX265	FTX.007.265	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.	FTX265 Values
FTX264	FTX.007.264	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.	FTX264 Values
FTX267	FTX.007.267	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
FTX268	FTX.007.268	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.	FTX268 Values
FTX269	FTX.007.269	FUNDING-CODE	A code to indicate the source of non-federal share funds.	FTX269 Values
FTX270	FTX.007.270	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.	FTX270 Values
FTX271	FTX.007.271	SOURCE-LOCATION	The field denotes the claims/transaction processing system in which the claims/transactions were originally processed.	FTX271 Values
FTX272	FTX.007.272	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
FTX273	FTX.007.273	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
FTX274	FTX.007.274	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.	FTX274 Values
FTX275	FTX.007.275	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
FTX276	FTX.007.276	MEMO	This represents any notes from the state's ledger/accounting system associated with the payment/recoupment.	N/A
FTX277	FTX.007.277	STATE-NOTATION	A free text field for the submitting state to enter whatever information it chooses.	N/A

Definition: A record segment to capture state directed payments which are made under separate payment terms.
File Segment Length: 2500

Published Date	Data Guide Version	File Segment	Action	Field	Before	After
10/16/2024	4.0.0	STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM	UPDATE	Record segment definition	A record segment to capture State Directed Payment Separate Payment Term payments.	A record segment to capture State Directed Payments which are made under separate payment terms.
09/16/2024	4.0.0	STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM	ADD	N/A		Created