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Data Element
CLT205
CLT.003.205
Definition | The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed care encounters the Allowed Amount is determined by the managed care organization. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity allowed at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
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Size | S9(11)V99 |
FLF Start Position | 220 |
FLF Stop Position | 232 |
Segment Key Field Identifier | Not Applicable |
Coding Requirements | 1. Value must be between -99999999999.99 and 99999999999.99 |
Valid Value Code Set | Valid Value Code | Valid Value Name | Valid Value Description | Effective Start Date | Effective End Date |
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DE Number | System DE Number | DE Name | File Segment Number | File Segment Name |
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CIP252 | CIP.003.252 | ALLOWED-AMT | CIP00003 | CLAIM-LINE-RECORD-IP |
COT175 | COT.003.175 | ALLOWED-AMT | COT00003 | CLAIM-LINE-RECORD-OT |
CRX122 | CRX.003.122 | ALLOWED-AMT | CRX00003 | CLAIM-LINE-RECORD-RX |