COT.002.037

TYPE-OF-CLAIM

Data Element

DE Number

COT037

System DE Number

COT.002.037

File Name

COT - CLAIM OTHER

File Segment Number

COT00002

File Segment Name

CLAIM-HEADER-RECORD-OT

Last updated

Overview Valid Values Related Rules Related DQ Measures Other Instances

Definition	A code to indicate what type of payment is covered in this claim. For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record. For sub-capitation payments, report TYPE-OF-CLAIM = '6' or “F”.
Size	X(1)
FLF Start Position	210
FLF Stop Position	210
Segment Key Field Identifier	Not Applicable
Coding Requirements	1. Value must be in Type of Claim List (VVL) 2. Value must be 1 character 3. Mandatory 4. When value equals 'Z', claim denied indicator must equal '0'

Valid Value Code Set	Valid Value Code	Valid Value Name	Valid Value Description	Effective Start Date	Effective End Date

RULE ID	RULE Definition
RULE-7741	If a claim in a non-denied, original or adjustment Encounter crossover claim from an OT file, and the MSIS ID is populated and the beginning date of service is populated with a date that overlaps with the reported eligibility determinant effective and end dates, and the primary eligibility group indicator is equal to '1', then the dual eligible code is equal to '01', '02', '04', '08'
RULE-7983	If a claim in a non-denied, original or adjustment FFS crossover claim from an OT file, and the MSIS ID is populated and the beginning date of service is populated with a date that overlaps with the reported eligibility determinant effective and end dates, and the primary eligibility group indicator is equal to '1', then the dual eligible code is equal to '01', '02', '04', '08'
RULE-1370	If the type of claim is populated on a non-denied claim from an OT file, then the type of claim value reported must be in the list of valid values for type of claim.
RULE-6352	If a claim is a non-denied claim from an OT file, then the type of claim value reported must be compatible with specified T-MSIS picture format: X(1).
RULE-7256	If a claim is a non-denied claim from an OT file, then the type of claim value must be populated.
RULE-7295
RULE-7424	If a claim in a non-denied, original or adjustment FFS or Encounter crossover claim from an OT file, and the MSIS ID is populated and the beginning date of service is populated with a date that overlaps with the reported eligibility determinant effective and end dates, and the primary eligibility group indicator is equal to '1', then the dual eligible code is equal to '01', '02', '04', '08'
RULE-7552	If the 1115A demonstration indicator is equal to 1 (yes) on a non-denied claim from an OT file, and the beginning date of service is within the 1115A effective and end dates, then the 1115A demonstration indicator value reported on the 1115A demonstration information segment must be populated with a 1 value.
RULE-7582	If a claim line is a non-denied, paid claim from an OT file, and the claim line type of service is equal to supplemental payments for outpatient (134), then the type of claim is a Medicaid/Medicaid expansion CHIP, Separate CHIP or Other service tracking claim.
RULE-7635	All non-denied, paid OT claim header records must have a corresponding non-denied claim line record.
RULE-7772	If a claim is a non-denied claim from an OT file, and the waiver type is populated, and the claim beginning date of service is between the waiver enrollment effective and end dates, then the claim waiver type is equal to the waiver participation waiver type.

Measure ID	Measure Name
MCR-65-012-12	% of Integrated Care for Dual Eligibles (MANAGED-CARE-PLAN-TYPE = 80) enrollees with no capitation payments for Integrated Care for Dual Eligibles
MCR-65-001-1	% of Comprehensive MCO (MANAGED-CARE-PLAN-TYPE = 01, 04) enrollees with no capitation payments for comprehensive MCO
MCR-65-002-2	% of PACE plan (MANAGED-CARE-PLAN-TYPE = 17) enrollees with no capitation payments for PACE
MCR-65-003-3	% of Transportation PAHP (MANAGED-CARE-PLAN-TYPE = 15) enrollees with no capitation payments for Transportation PAHPs
MCR-65-004-4	% of Dental PAHP (MANAGED-CARE-PLAN-TYPE = 14) enrollees with no capitation payments for Dental PAHPs
MCR-65-005-5	% of Pharmacy PAHP (MANAGED-CARE-PLAN-TYPE = 18) enrollees with no capitation payments for Pharmacy PAHPs
MCR-65-006-6	% of Mental Health PIHP (MANAGED-CARE-PLAN-TYPE = 08, 10, 12) enrollees with no capitation payments for Mental Health PIHPs
MCR-65-007-7	% of Mental Health PAHP (MANAGED-CARE-PLAN-TYPE = 09, 11, 13) enrollees with no capitation payments for Mental Health PAHPs
MCR-65-008-8	% of LTSS (MANAGED-CARE-PLAN-TYPE = 07, 19) enrollees with no capitation payments for LTSS
MCR-65-009-9	% of Disease Management (MANAGED-CARE-PLAN-TYPE = 02, 03, 16) enrollees with no capitation payments for Disease Management
MCR-65-010-10	% of ACO (MANAGED-CARE-PLAN-TYPE = 60) enrollees with no capitation payments for ACOs
MCR-65-011-11	% of Health/Medical Home (MANAGED-CARE-PLAN-TYPE = 70) enrollees with no capitation payments for Health/Medical Home
RULE-7564	% of claim headers with a Procedure Code indicating a dental claim and non-missing Diagnosis Code Flag 1 that have a missing Diagnosis Code 1
EL-8-001-1	Enrollment, capitation payments, and encounters by Plan Type
EXP-26-001-1	Capitation payments by Plan ID (non-PCCM)
EXP-26-002-2	% of total capitation amount paid on Plan IDs not found in Managed Care file
EXP-26-003-3	% of total capitation amount paid with unknown or non-specified Plan IDs
MCR-27-001-1	Encounters (by Claim File Type)
MCR-27-002-2	Encounters (by Claims file type) by Plan ID (non-PCCM)
MIS-6-034-34	% missing: TYPE-OF-CLAIM (COT00002)
MCR-12-156-156	# of claim headers where the claim type indicates a sub-capitation payment (TYPE-OF-CLAIM = 6)
MCR-12-157-157	# of claim headers where the claim type indicates a sub-capitation payment (TYPE-OF-CLAIM = F)
RULE-7256	% missing: TYPE-OF-CLAIM (COT00002)
MCR-54-001-1	# of plans with at least 100 enrollments, 0 capitations, 0 encounters
ALL-24-001-1	Type of Claim values
ALL-27-001-1	# of Medicaid service tracking claim headers (TYPE-OF-CLAIM = 4)
ALL-27-002-2	# of Medicaid supplemental claim headers (TYPE-OF-CLAIM = 5)
EL-8-002-2	Enrollment, capitation payments, capitation ratios, encounters (by claim file type) and encounter ratios (by claim file type) by plan ID with plan ID linking to MC file
EXP-43-003-3	# of non-service tracking claim headers with non-missing Service Tracking Type
EXP-43-007-7	# of non-service tracking claim headers with non-missing Service Tracking Payment Amount
MCR-28-001-1	% of plan IDs with capitation payment ratios <0.9 or >1.1 (non-PCCM)
MCR-53-001-1	Total # of managed care enrollments
MCR-53-002-2	Total # of managed care capitations
MCR-53-003-3	Total # of managed care encounters
ALL-18-003-3	# of claim headers with TYPE-OF-CLAIM = U, V, W, X or Y that aren’t MFP (PROGRAM-TYPE = 08)
MCR-54-002-2	# of plans with at least 100 enrollments or 100 capitations, 0 encounters
MCR-54-003-3	# of plans with at least 100 enrollments or 100 encounters, 0 capitations
MCR-54-004-4	# of plans with at least 100 enrollments and some capitations that have capitation ratios outside of the expected range (0.7 - 1.3)
MCR-54-005-5	# of plans with at least 100 capitations or 100 encounters, 0 enrollments
MCR-54-009-9	# of plans with at least 100 enrollments, capitations, or encounters, that do not have a managed care record
MCR-54-010-10	# of plans where MC plan type does not match EL plan type
MCR-55-001-1	Traditional PCCM capitation ratio
MCR-55-002-2	Enhanced PCCM capitation ratio
MCR-55-003-3	PACE capitation ratio
MIS-17-001-1	% missing: TYPE-OF-CLAIM (COT00002)

DE Number	System DE Number	DE Name	File Segment Number	File Segment Name
CIP100	CIP.002.100	TYPE-OF-CLAIM	CIP00002	CLAIM-HEADER-RECORD-IP
CLT052	CLT.002.052	TYPE-OF-CLAIM	CLT00002	CLAIM-HEADER-RECORD-LT
CRX029	CRX.002.029	TYPE-OF-CLAIM	CRX00002	CLAIM-HEADER-RECORD-RX

Published Date	Data Guide Version	Data Element	Action	Field	Before	After
08/11/2023	3.11.0	COT.002.037	UPDATE	Definition	A code to indicate what type of payment is covered in this claim.For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record.	A code to indicate what type of payment is covered in this claim.For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record.For sub-capitation payments, report TYPE-OF-CLAIM = '6' or “F”.
08/11/2023	3.11.0	COT.002.037	UPDATE	Last update date	8/9/2023	8/11/2023
08/09/2023	3.11.0	COT.002.037	UPDATE	Definition	A code to indicate what type of payment is covered in this claim.	A code to indicate what type of payment is covered in this claim.For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record.
08/09/2023	3.11.0	COT.002.037	UPDATE	Last update date	12/08/2022	8/9/2023
05/08/2020	2.4.0	TYPE-OF-CLAIM	UPDATE	Data Dictionary - Valid Values	Code \| Description Z \| Denied Claimes	N/A
07/15/2022	3.0.1	COT037	UPDATE	Data Dictionary	DE NO\| DATA ELEMENT NAME COMPUTING\|DEFINITION COT037\|TYPE-OF-CLAIM\|A code to indicate what type of payment is covered in this claim.	DE NO\| DATA ELEMENT NAME COMPUTING\|DEFINITION COT037\|TYPE-OF-CLAIM\|A code to indicate what type of payment is covered in this claim. For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record. For sub-capitation payments, report TYPE-OF-CLAIM = '6' or “F”.