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Data Element
COT068
COT.002.068
Definition | The field denotes whether the payment amount was determined at the claim header or line/detail level. For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header. For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed. For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
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Size | X(1) |
FLF Start Position | 396 |
FLF Stop Position | 396 |
Segment Key Field Identifier | Not Applicable |
Coding Requirements | 1. Value must be in Payment Level Indicator List (VVL) |
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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CIP132 | CIP.002.132 | PAYMENT-LEVEL-IND | CIP00002 | CLAIM-HEADER-RECORD-IP |
CLT082 | CLT.002.082 | PAYMENT-LEVEL-IND | CLT00002 | CLAIM-HEADER-RECORD-LT |
CRX058 | CRX.002.058 | PAYMENT-LEVEL-IND | CRX00002 | CLAIM-HEADER-RECORD-RX |