COT.003.175

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TMSIS Dataguide

Medicaid.gov

Version 3.36.0

ALLOWED-AMT

Data Element

DE Number

COT175

System DE Number

COT.003.175

File Name

COT - CLAIM OTHER

File Segment Number

File Segment Name

CLAIM-LINE-RECORD-OT

Last updated

Overview Valid Values Related Rules Related DQ Measures Other Instances

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.
Size	S9(11)V99
FLF Start Position	222
FLF Stop Position	234
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. Conditional 4. When Type of Claim is in [1,A], Medicaid Paid Amount (COT.003.177) is less than or equal to the value submitted

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

RULE ID	RULE Definition
RULE-1646	If a claim line is a non-denied claim line from an OT file, then the allowed amount value reported must be a valid dollar amount that matches the specified T-MSIS picture format: S9(11)V99.
RULE-7285	If a claim is a non-denied claim from an OT file that is an original claim and is a separate CHIP FFS or Medicaid or Medicaid-expansion CHIP FFS claim and the payment level indicator is equal to 2 and the medicaid paid amount is populated, then the claim line medicaid paid amount is less than or equal to the line total allowed amount.

Measure ID	Measure Name
FFS-49-011-11	% of claim lines with PAYMENT-LEVEL-IND=2 (claim detail) that have Medicaid Paid Amount greater than a non-zero Allowed Amount
MCR-59-011-11	% of claim lines with PAYMENT-LEVEL-IND=2 (claim detail) that have Medicaid Paid Amount greater than a non-zero Allowed Amount
MIS-7-001_1-33	% missing: ALLOWED-AMT (COT00003)
MIS-26-002-2	% missing: ALLOWED-AMT (COT00003)
MIS-84-001-1	% missing: ALLOWED-AMT (COT00003)

DE Number	System DE Number	DE Name	File Segment Number	File Segment Name
CIP252	CIP.003.252	ALLOWED-AMT	CIP00003	CLAIM-LINE-RECORD-IP
CLT205	CLT.003.205	ALLOWED-AMT	CLT00003	CLAIM-LINE-RECORD-LT
CRX122	CRX.003.122	ALLOWED-AMT	CRX00003	CLAIM-LINE-RECORD-RX

Published Date	Data Guide Version	Data Element	Action	Field	Before	After
09/12/2024	3.29.0	COT.003.175	UPDATE	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.	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.
09/12/2024	3.29.0	COT.003.175	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. Conditional4. When Type of Claim is in ['1', 'A'}, Medicaid Paid Amount (COT.003.177) is less than or equal to the value submitted	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. Conditional4. When Type of Claim is in [1,A], Medicaid Paid Amount (COT.003.177) is less than or equal to the value submitted
08/15/2023	3.12.0	COT.003.175	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. 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. Conditional4. When Type of Claim is in ['1', 'A'}, Medicaid Paid Amount (COT.003.177) is less than or equal to the value submitted
08/09/2023	3.11.0	COT.003.175	UPDATE	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.	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.
07/15/2022	3.0.1	COT175	UPDATE	Data Dictionary	DE NO\| DATA ELEMENT NAME COMPUTING\|DEFINITION COT175\|ALLOWED-AMT\|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.	DE NO\| DATA ELEMENT NAME COMPUTING\|DEFINITION COT175\|ALLOWED-AMT\|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.