COT.002.049

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TMSIS Dataguide

Medicaid.gov

Version 3.36.0

TOT-ALLOWED-AMT

Data Element

DE Number

COT049

System DE Number

COT.002.049

File Name

COT - CLAIM OTHER

File Segment Number

File Segment Name

CLAIM-HEADER-RECORD-OT

Last updated

Overview Valid Values Related Rules Related DQ Measures Other Instances

Definition	The claim header level maximum amount determined by the payer as being "allowable" under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state"s MMIS. 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 total amount that the sub-capitated entity allowed for the service. 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.
Size	S9(11)V99
FLF Start Position	279
FLF Stop Position	291
Segment Key Field Identifier	Not Applicable
Coding Requirements	1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. When populated and Payment Level Indicator equals "2" then value must equal the sum of all claim line Allowed Amount values 4. Conditional

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

RULE ID	RULE Definition
RULE-1392	If a claim is a non-denied claim from an OT file, then the total allowed amount value reported must be a valid dollar amount that matches the specified T-MSIS picture format: S9(11)V99.
RULE-1393	If the total allowed amount is populated on a non-denied claim from an OT file, then the total allowed amount must equal the sum of all line-level allowed amounts.
RULE-7284	If a claim is a non-denied claim from an OT file that is an original claim and is a Medicaid or Medicaid-expansion CHIP FFS, Medicaid or Medicaid-expansion CHIP encounter, separate CHIP FFS or encounter claim and the total medicaid paid amount is populated, then the total medicaid paid amount is less than or equal to the total allowed amount.
RULE-7688	If a claim is a non-denied claim from an OT file that is an original claim and is a Medicaid or Medicaid-expansion CHIP encounter, separate CHIP encounter claim and the total medicaid paid amount is populated, then the total medicaid paid amount is less than or equal to the total allowed amount.
RULE-7796	If a claim is a non-denied claim from an OT file that is an original claim and is a Medicaid or Medicaid-expansion CHIP or Separate CHIP Fee-for-Service claim and the total medicaid paid amount is populated, then the total medicaid paid amount is less than or equal to the total allowed amount.

Measure ID	Measure Name
FFS-49-007-7	% of claim headers that have Total Medicaid Paid Amount greater than a non-zero Total Allowed Amount
MCR-59-007-7	% of claim headers that have Total Medicaid Paid Amount greater than a non-zero Total Allowed Amount
MIS-6-027_2-39	% missing: TOT-ALLOWED-AMT (COT00002)
MIS-25-029-29	% missing: TOT-ALLOWED-AMT (COT00002)
MIS-83-029-29	% missing: TOT-ALLOWED-AMT (COT00002)

DE Number	System DE Number	DE Name	File Segment Number	File Segment Name
CIP113	CIP.002.113	TOT-ALLOWED-AMT	CIP00002	CLAIM-HEADER-RECORD-IP
CLT064	CLT.002.064	TOT-ALLOWED-AMT	CLT00002	CLAIM-HEADER-RECORD-LT
CRX040	CRX.002.040	TOT-ALLOWED-AMT	CRX00002	CLAIM-HEADER-RECORD-RX

Published Date	Data Guide Version	Data Element	Action	Field	Before	After
09/12/2024	3.29.0	COT.002.049	UPDATE	Definition	The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. 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 total amount that the sub-capitated entity allowed for the service. 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.	The claim header level maximum amount determined by the payer as being "allowable" under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state"s MMIS. 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 total amount that the sub-capitated entity allowed for the service. 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.
09/12/2024	3.29.0	COT.002.049	UPDATE	Coding requirement	1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. When populated and Payment Level Indicator = '2' then value must equal the sum of all claim line Allowed Amount values4. Conditional	1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. When populated and Payment Level Indicator equals "2" then value must equal the sum of all claim line Allowed Amount values4. Conditional
08/09/2023	3.11.0	COT.002.049	UPDATE	Definition	The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. On managed care encounters the Allowed Amount is determined by the managed care organization.	The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. 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 total amount that the sub-capitated entity allowed for the service. 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.
07/15/2022	3.0.1	COT049	UPDATE	Data Dictionary	DE NO\| DATA ELEMENT NAME COMPUTING\|DEFINITION COT049\|TOT-ALLOWED-AMT\|The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. On managed care encounters the Allowed Amount is determined by the managed care organization.	DE NO\| DATA ELEMENT NAME COMPUTING\|DEFINITION COT049\|TOT-ALLOWED-AMT\|The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. 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 total amount that the sub-capitated entity allowed for the service. 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.