COT.002.066

PLAN-ID-NUMBER

Data Element

DE Number

COT066

System DE Number

COT.002.066

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 unique number assigned by the state which represents a distinct comprehensive managed care plan, prepaid health plan, primary care case management program, a program for all-inclusive care for the elderly entity, or other approved plans. For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report the PLAN-ID-NUMBER for the MCP (MCO, PIHP, or PAHP that has a contract with a state) that is making the payment to the sub-capitated entity or 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	X(12)
FLF Start Position	384
FLF Stop Position	395
Segment Key Field Identifier	Not Applicable
Coding Requirements	1. Value must be 12 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Conditional 4. Value must match Managed Care Plan ID (ELG.014.192) 5. Value must match State Plan ID Number (MCR.002.019) 6. When Type of Claim (COT.002.037) in (3, C, W, 2, B, V) value must have a managed care enrollment (ELG.014) for the beneficiary where the Beginning DOS (COT.002.033) occurs between the managed care plan enrollment eff/end dates (ELG.014.197/198) 7. When Type of Claim (COT.002.037) in (3, C, W, 2, B, V) value must have a managed care main record (MCR.002) for the plan where the Beginning DOS (COT.002.033) occurs between the managed care contract eff/end dates (MCR.002.020/021)

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

RULE ID	RULE Definition
RULE-1421	If the plan ID number is populated on a non-denied claim from an OT file, then the plan ID number reported must not contain any pipe or asterisk characters.
RULE-6520	If a claim is a non-denied claim from an OT file, then the plan ID number value reported must be compatible with specified T-MSIS picture format: X(12).
RULE-7196	If plan ID is populated on a non-denied, non-void Medicaid, S-CHIP, or Other encounter from an OT file, then the plan ID must be equal to the plan ID on a managed care participation segment from an ELG file with the same MSIS ID and enrollment effective and end dates that overlap the beginning date of service.
RULE-7200	If plan ID is populated on a non-denied Medicaid, S-CHIP, or Other encounter from an OT file, then the plan ID must be equal to the plan ID on a managed care main segment from an MCR file where the beginning date of service on the claim is within the contract effective and end dates on the managed care main segment.
RULE-7702	If plan ID is populated on a non-denied Medicaid, S-CHIP, or Other capitation from an OT file, then the plan ID must be equal to the plan ID on a managed care main segment from an MCR file where the beginning date of service on the claim is within the contract effective and end dates on the managed care main segment.
RULE-7706	If plan ID is populated on a non-denied Medicaid, S-CHIP, or Other capitation from an OT file, then the plan ID must be equal to the plan ID on a managed care participation segment from an ELG file with the same MSIS ID and effective and end dates that overlap the beginning date of service.

Measure ID	Measure Name
EL-8-001-1	Enrollment, capitation payments, and encounters by Plan Type
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
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
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
MCR-27-002-2	Encounters (by Claims file type) by Plan ID (non-PCCM)
MCR-13-018-20	% of PHP (TYPE-OF-SERVICE ) capitation payments with a non-missing plan ID that do not have a corresponding managed care participation PHP plan
MCR-9-018-20	% of PHP (TYPE-OF-SERVICE ) capitation payments with a non-missing plan ID that do not have a corresponding managed care participation PHP plan
MCR-13-019-21	% of Comprehensive MCO (TYPE-OF-SERVICE) capitation payments with a non-missing plan ID that do not have a corresponding managed care participation Comprehensive MCO plan
MCR-9-019-21	% of Comprehensive MCO (TYPE-OF-SERVICE) capitation payments with a non-missing plan ID that do not have a corresponding managed care participation Comprehensive MCO plan
RULE-7196	% of claim headers with a valid value for Plan ID Number that do not have a corresponding ELG Managed Care Participation segment for the same time period
RULE-7200	% of claim headers with a valid value for Plan ID Number that do not have a corresponding MCR Managed Care Main segment for the same time period
RULE-7702	% of claim headers with a valid value for Plan ID Number that do not have a corresponding MCR Managed Care Main segment for the same time period
RULE-7706	% of claim headers with a valid value for Plan ID Number that do not have a corresponding ELG Managed Care Participation segment for the same time period
MCR-54-005-5	# of plans with at least 100 capitations or 100 encounters, 0 enrollments
MCR-13-005-4	% of claim lines with plan ID
MCR-13-006_1-18	% of PCCM (TYPE-OF-SERVICE) capitation payments with a non-missing plan ID that do not have a corresponding managed care participation PCCM plan
MCR-13-006_2-19	% of PCCM capitated payments with a non-missing plan ID where plan ID number equals the Billing Provider Number or Billing Provider NPI Number
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
MCR-54-001-1	# of plans with at least 100 enrollments, 0 capitations, 0 encounters
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)
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
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
MCR-9-005-4	% of claim lines with plan ID
MCR-9-006_1-18	% of PCCM (TYPE-OF-SERVICE) capitation payments with a non-missing plan ID that do not have a corresponding managed care participation PCCM plan
MCR-9-006_2-19	% of PCCM capitated payments with a non-missing plan ID where plan ID number equals the Billing Provider Number or Billing Provider NPI Number
MIS-6-026-26	% missing: PLAN-ID-NUMBER (COT00002)
MIS-25-027-27	% missing: PLAN-ID-NUMBER (COT00002)
MIS-83-027-27	% missing: PLAN-ID-NUMBER (COT00002)

DE Number	System DE Number	DE Name	File Segment Number	File Segment Name
CIP130	CIP.002.130	PLAN-ID-NUMBER	CIP00002	CLAIM-HEADER-RECORD-IP
CLT080	CLT.002.080	PLAN-ID-NUMBER	CLT00002	CLAIM-HEADER-RECORD-LT
CRX056	CRX.002.056	PLAN-ID-NUMBER	CRX00002	CLAIM-HEADER-RECORD-RX

Published Date	Data Guide Version	Data Element	Action	Field	Before	After
08/09/2023	3.11.0	COT.002.066	UPDATE	Definition	A unique number assigned by the state which represents a distinct comprehensive managed care plan, prepaid health plan, primary care case management program, a program for all-inclusive care for the elderly entity, or other approved plans.	A unique number assigned by the state which represents a distinct comprehensive managed care plan, prepaid health plan, primary care case management program, a program for all-inclusive care for the elderly entity, or other approved plans.For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report the PLAN-ID-NUMBER for the MCP (MCO, PIHP, or PAHP that has a contract with a state) that is making the payment to the sub-capitated entity or 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	COT066	UPDATE	Data Dictionary	DE NO\| DATA ELEMENT NAME COMPUTING\|DEFINITION COT066\|PLAN-ID-NUMBER\|A unique number assigned by the state which represents a distinct comprehensive managed care plan, prepaid health plan, primary care case management program, a program for all-inclusive care for the elderly entity, or other approved plans.	DE NO\| DATA ELEMENT NAME COMPUTING\|DEFINITION COT066\|PLAN-ID-NUMBER\|A unique number assigned by the state which represents a distinct comprehensive managed care plan, prepaid health plan, primary care case management program, a program for all-inclusive care for the elderly entity, or other approved plans. For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report the PLAN-ID-NUMBER for the MCP (MCO, PIHP, or PAHP that has a contract with a state) that is making the payment to the sub-capitated entity or sub-capitated network provider. For sub-capitation payments, report the PLAN-ID-NUMBER for the managed care plan making the payment to the sub-capitated entity.