CMS Technical Instructions: Reporting Amounts Paid to Providers in T-MSIS

This reporting reminder describes T-MSIS data elements that collect payments to providers for covered services on a claim. This reporting reminder is applicable to Medicaid and Children’s Health Insurance Program (CHIP) fee for service (FFS) claims and managed care encounters. It does not cover instances when the Medicaid agency or managed care plan pays towards a beneficiary’s Medicare coinsurance and deductible amounts (also called ‘cross-over’ claims).^[1]

The T-MSIS data dictionary defines “Allowed Amount” as the maximum amount “determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment.”^[2] There are situations where only one payer is liable for paying the provider, and other situations where multiple payers (e.g., the State Medicaid or CHIP Agency, hereby referred to as the state agency, a managed care organization (MCO), the beneficiary, Medicare, or a third party) are liable. In T-MSIS, the Total Allowed Amount (TOT-ALLOWED-AMT: CIP113, CLT064, COT049, CRX040) data element collects the maximum amount, as determined by the state agency or MCO, that the provider will be paid for covered services on a Medicaid or CHIP claim. Because Medicaid is, in general, the payer of last resort^[3], in the instances where there is a third party liable for services also covered by Medicaid, an accounting of the third-party liability (TPL) is used to determine how much of the Medicaid allowed amount, if any, remains due to the provider. If, after the Medicare liability and TPL is accounted for, a provider was paid less than the Medicaid-determined allowed amount, Medicaid pays the provider the Medicaid allowed amount minus the Medicare payment, TPL payment, and beneficiary cost sharing.
Currently, T-MSIS collects payment amounts made by the state agency or MCO, beneficiaries, Medicare, and third parties for covered services on a claim. Together, these payments to the provider (for the Medicaid or CHIP covered services on a claim) determine if the provider has been appropriately paid for the services provided to the beneficiary.

Total Medicaid (or CHIP) Payment is less than or equal to the Total Medicaid (or CHIP) Allowed Amount minus the sum of the Total Beneficiary Cost Sharing Payments and Total Third-Party Payments for Medicaid (or CHIP) Covered Services.

If the Total Third-Party Payment for Medicaid (or CHIP) covered services is greater than or equal to the Total Medicaid (or CHIP) Allowed Amount, then the Total Medicaid (or CHIP) Payment and Total Beneficiary Cost Sharing Payments should be zero.

Medicaid (or CHIP) payment (or, for encounter records, a managed care organization’s payment) to the provider for covered services is the amount that Medicaid (or CHIP) pays the provider for covered services on a claim. The amount Medicaid (or CHIP) pays is based on the Medicaid- (or CHIP-) determined allowed amount minus the beneficiary cost sharing and TPL payments. If the TPL payments for the Medicaid (or CHIP) covered services are equal to or exceed the Medicaid- (or CHIP-) determined allowed amount, the Medicaid (or CHIP) payment and Beneficiary cost sharing should be zero.

The Total Medicaid Paid Amount (TOT-MEDICAID-PAID-AMT: CIP114, CLT065, COT050, CRX041) data element collects the total amount the state agency or MCO paid toward the Total Allowed Amount (TOT-ALLOWED-AMT: CIP113, CLT064, COT049, CRX040) for covered services on a claim.^[4]

Beneficiary cost sharing payments^[5] are the portion of the state agency or MCO determined allowed amount the beneficiary paid, and is usually in the form of a copayment, coinsurance, or payment towards a deductible. There may be instances where a beneficiary does not pay all or any of their liable amount. In such cases, the Total Medicaid (or CHIP) Allowed Amount may be greater than the sum of the amounts paid by the state agency or MCO, the TPL, and the beneficiary on a claim.

The Total Allowed Amount (TOT-ALLOWED-AMT: CIP113, CLT064, COT049, CRX040) data elements collect the Medicaid (or CHIP) allowed amounts on the entire claim. The Total Beneficiary Copayment Paid Amount (TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT: CIP208, CLT155, COT132, CRX089), Beneficiary Copayment Paid Amount (BENEFICIARY-COPAYMENT-PAID-AMOUNT: COT176, CRX123), Total Beneficiary Coinsurance Paid Amount (TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT: CIP206, CLT153, COT130, CRX087), and Total Beneficiary Deductible Paid Amount (TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT: CIP210, CLT157, COT134, CRX092) collect the respective copayment, coinsurance, and deductible amounts the beneficiary paid for covered services on a claim or claim line. The COMBINED-BENE-COST-SHARING-PAID-AMOUNT (CIP295, CLT242, COT233, CRX166) captures the combined amount paid by the beneficiary towards the copayment, coinsurance, and/or deductible payments when the claim does not differentiate among the payment types.

Third party payments^[6] refers to the amount the third party pays for covered services based on the TPL estimated allowed amount. In some instances, third-party allowed amounts (and therefore, payments) for Medicaid (or CHIP) covered services are less than the Medicaid (or CHIP) determined allowed amount; in other instances, third-party allowed amounts (and therefore, payments) are equal to or greater than the Medicaid (or CHIP) determined allowed amount.

The Total Third Party Liability Amount (TOT-TPL-AMT: CIP118, CLT069, COT054, CRX045), Third Party Liability Amount (TPL-AMT: CIP253, CLT206, COT177, CRX124), Total Other Insurance Amount (TOT-OTHER-INSURANCE-AMT: CIP119, CLT070, COT056, CRX047), Other Insurance Amount (OTHER-INSURANCE-AMT: CIP272, CLT207, COT213, CRX152), Third Party Copayment Amount Paid (THIRD-PARTY-COPAYMENT-AMOUNT-PAID: CIP218, CLT165, COT142, CRX100), and Third Party Coinsurance Amount Paid (THIRD-PARTY-COINSURANCE-AMOUNT-PAID: CIP216, CLT163, COT140, CRX098) data elements collect the amounts the third party paid for covered services.

State Directed payments^[7] refers to the delivery system and provider payment initiatives under MCO, PIHP, or PAHP Medicaid managed care contracts as described in 42 C.F.R. § 438.6(c). These permissible state directed payments may include: value-based purchasing models, multi-payer or Medicaid-specific delivery system reform or performance improvement initiatives, or fee schedule requirements for provider reimbursement (e.g., minimum fee schedules, maximum fee schedules, and uniform increases).

The Total SDP Paid Amount (TOT-SDP-PAID-AMT^[8]: CIP339, CLT259, COT253, CRX178) collects the component of the Total Medicaid Paid Amount (TOT-MEDICAID-PAID-AMT: CIP114, CLT065, COT050, CRX041) that represents the difference between what would have been the managed care’s typical contractual paid amount and the enhanced paid amount for a specific encounter as allowed by 42 CFR 438.6(c)(iii) and as defined by the State’s SPA, waiver, or demonstration for a State Directed Payment model. SDP Paid Amount (SDP-PAID-AMT8: CIP337, CLT267, COT273, and CRX195) collects the difference at the line level.

The Total SDP Allowed Amount (TOT-SDP-ALLOWED-AMT8: CIP338, CLT258, COT252, CRX177) data element collects the difference between what would have been the managed care plan's typical contractual allowed amount and the enhanced allowed amount for a specific encounter as allowed by 42 CFR 438.6(c)(iii) and as defined by the State's SPA, waiver, or demonstration for a State Directed Payment model. The difference between the Total SDP Allowed Amount and the Total SPD Paid Amount would represent any applicable beneficiary cost-sharing or third-party payments.

Graduate Medical Education (GME) payments refer to the amount included in the Total Medicaid Paid Amount that represents a GME payment. States should not report to T-MSIS financial transactions for lump-sum payments to providers for GME. However if as a component of the Medicaid paid amount for an FFS claim, the state includes a GME component to the payment, the GME component of the Medicaid paid amount should be reported to Total GME Amount Paid (TOT-GME-AMOUNT-PAID8: CIP311, CLT257, COT249, CRX176) and, when applicable, GME Amount Paid (GME-AMOUNT-PAID8: CIP317, CLT263, COT265, CRX193).

Disproportionate Share Hospital (DSH) payments refer to the amount included in the Total Medicaid Paid Amount of a CIP claim that represents a DSH payment. States should not report to T-MSIS financial transactions for lump-sum payments to providers for DSH. However, if as a component of the Total Medicaid Paid Amount for an FFS claim, the state includes a DSH component to the payment, the DSH component of the Total Medicaid Paid Amount should be reported to Medicaid Amount Paid DSH (MEDICAID-AMOUNT-PAID-DSH: CIP220).

Table 1. T-MSIS Data Elements Collecting Amounts Paid to a Provider for Covered Services