CRX.002.025

ADJUSTMENT-IND

Data Element

DE Number

CRX025

System DE Number

CRX.002.025

File Name

CRX - CLAIM PHARMACY

File Segment Number

CRX00002

File Segment Name

CLAIM-HEADER-RECORD-RX

Last updated

Overview Valid Values Related Rules Related DQ Measures Other Instances

Definition	Indicates the type of adjustment record.
Size	X(1)
FLF Start Position	156
FLF Stop Position	156
Segment Key Field Identifier	4
Coding Requirements	1. Value must be in Adjustment Indicator List (VVL) 2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ] 3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ] 4. Value must be 1 character 5. Mandatory 6. If value is in [‘0’, ‘5’, ‘6’ ], then associated Adjustment ICN must not be populated 7. If value is in [‘4’, ‘1’] then Adjustment ICN must be populated 8. Value must equal ‘1’, when associated Claim Status equals ‘686’

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

RULE ID	RULE Definition
RULE-7650	If a segment is an RX claim header, and the type of claim is an encounter, the adjustment indicator must be populated.
RULE-7984	If a claim in a non-denied, original or adjustment FFS crossover claim from an RX file, and the MSIS ID is populated and the presription fill date 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-7742	If a claim in a non-denied, original or adjustment Encounter crossover claim from an RX file, and the MSIS ID is populated and the presription fill date 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-7414	If a claim in a non-denied, original or adjustment FFS or Encounter crossover claim from an RX file, and the MSIS ID is populated and the prescription fill date 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-7887	If the type of claim is a service tracking and adjustment indicator is populated on a claim header from an RX file, then the adjustment indicator value reported must be in the list of valid values for adjustment indicator.
RULE-7879	If the type of claim is a supplemental and adjustment indicator is populated on a claim header from an RX file, then the adjustment indicator value reported must be in the list of valid values for adjustment indicator.
RULE-7871	If the type of claim is a fee-for-service and adjustment indicator is populated on a claim header from an RX file, then the adjustment indicator value reported must be in the list of valid values for adjustment indicator.
RULE-7863	If a segment is an RX claim header, and the type of claim is a service tracking, the adjustment indicator must be populated.
RULE-7855	If a segment is an RX claim header, and the type of claim is a supplemental, the adjustment indicator must be populated.
RULE-7847	If a segment is an RX claim header, and the type of claim is a fee for service, the adjustment indicator must be populated.
RULE-7670	If the type of claim is an encounter and adjustment indicator is populated on a claim header from an RX file, then the adjustment indicator value reported must be in the list of valid values for adjustment indicator.
RULE-1762	If the adjustment indicator is populated on a claim header from an RX file, then the adjustment indicator value reported must be in the list of valid values for adjustment indicator.
RULE-7636	All non-denied, paid RX claim header records must have a corresponding non-denied claim line record.
RULE-7573	All denied RX claim header records must have a corresponding claim line record.
RULE-7544	If a segment is an RX claim header, and claim status is equal to '686' (void claim), then adjustment indicator must be equal to '1' (void).
RULE-7467	If a segment is an RX claim header, adjustment indicator must be populated.
RULE-7434	All non-denied RX claim header records must have a corresponding claim line record.
RULE-7348	If a segment is an RX claim header and icn adj is populated, then adjustment indicator is a replacement or resubmission payment or a void, reversal or canceled payment.
RULE-7340	If a segment is an RX claim header and icn adj is not populated, then the adjustment indicator is an original claim/encounter payment, credit gross adjustment or a debit gross adjustment payment.
RULE-7186	If a claim header is from an RX file, then submitting state, original ICN, adjustment ICN, adjudication date, and adjustment indicator values reported must be unique across all RX claim headers.
RULE-7125	If a claim is from an RX file, then the adjustment indicator value reported must be compatible with the specified T-MSIS picture format: X(1).

Measure ID	Measure Name
MCR-54-002-2	# of plans with at least 100 enrollments or 100 capitations, 0 encounters
MCR-27-001-1	Encounters (by Claim File Type)
EL-8-001-1	Enrollment, capitation payments, and encounters by Plan Type
RULE-7467	% of claim headers with a missing Adjustment Indicator
RULE-1762	% of claim headers with an invalid Adjustment Indicator (ADJUSTMENT-IND is 2, 3, 9, other invalid value)
MCR-S-019-21	% of claim headers that are original
MCR-S-015-10	% of claim headers that are original
MCR-55-003-3	PACE capitation ratio
MCR-55-002-2	Enhanced PCCM capitation ratio
MCR-55-001-1	Traditional PCCM capitation ratio
MCR-54-010-10	# of plans where MC plan type does not match EL plan type
MCR-54-009-9	# of plans with at least 100 enrollments, capitations, or encounters, that do not have a managed care record
MCR-54-005-5	# of plans with at least 100 capitations or 100 encounters, 0 enrollments
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-54-003-3	# of plans with at least 100 enrollments or 100 encounters, 0 capitations
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-54-001-1	# of plans with at least 100 enrollments, 0 capitations, 0 encounters
MCR-53-003-3	Total # of managed care encounters
MCR-53-002-2	Total # of managed care capitations
MCR-53-001-1	Total # of managed care enrollments
MCR-48-001-1	Adjustment Indicator values
MCR-37-001-1	Adjustment Indicator values
MCR-32-019-19	% of claim headers without a valid Adjustment Indicator (ADJ-IND is 2, 3, 9, other invalid value, or missing)
MCR-32-009-9	% of claim headers without a valid Adjustment Indicator (ADJ-IND is 2, 3, 9, other invalid value, or missing)
FFS-S-016-21	% of claim headers that are original
FFS-S-012-10	% of claim headers that are original
FFS-38-001-1	Adjustment Indicator values
FFS-30-001-1	Adjustment Indicator values
FFS-26-015-15	% of claim headers without a valid Adjustment Indicator (ADJ-IND is 2, 3, 9, other invalid value, or missing)

DE Number	System DE Number	DE Name	File Segment Number	File Segment Name
CIP026	CIP.002.026	ADJUSTMENT-IND	CIP00002	CLAIM-HEADER-RECORD-IP
CLT025	CLT.002.025	ADJUSTMENT-IND	CLT00002	CLAIM-HEADER-RECORD-LT
COT025	COT.002.025	ADJUSTMENT-IND	COT00002	CLAIM-HEADER-RECORD-OT

Published Date	Data Guide Version	Data Element	Action	Field	Before	After
11/07/2023	3.16.0	CRX.002.025	UPDATE	Segment key field identifier	Not Applicable	4
11/07/2023	3.16.0	CRX.002.025	UPDATE	Coding requirement	Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory6. If value is in [‘0’, ‘5’, ‘6’ ], then associated Adjustment ICN must not be populated7. If value is in [‘4’, ‘1’] then Adjustment ICN must be populated8. Value must equal ‘1’, when associated Claim Status equals ‘686’	1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory6. If value is in [‘0’, ‘5’, ‘6’ ], then associated Adjustment ICN must not be populated7. If value is in [‘4’, ‘1’] then Adjustment ICN must be populated8. Value must equal ‘1’, when associated Claim Status equals ‘686’
08/15/2023	3.12.0	CRX.002.025	UPDATE	Coding requirement	1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory	Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory6. If value is in [‘0’, ‘5’, ‘6’ ], then associated Adjustment ICN must not be populated7. If value is in [‘4’, ‘1’] then Adjustment ICN must be populated8. Value must equal ‘1’, when associated Claim Status equals ‘686’
08/07/2023	3.11.0	CRX.002.025	UPDATE	Coding requirement	1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim (CE) value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim (CE) value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory	1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory
10/02/2020	2.4.0	LINE-NUM-ADJ LINE-ADJUSTMENT-IND	UPDATE	Data Dictionary	\|DE No\|Data Element Name\|Coding Requirement\|CR No\| \|CIP238\|LINE-NUM-ADJ\|This field should be left blank or space-filled if the ADJUSTMENT-INDICATOR = 0. Otherwise, if there is a line adjustment indicator, then there should be a line adjustment number. \|Not Applicable\| \|CIP239\|LINE-ADJUSTMENT-IND\|If there is a line adjustment number, then there must be a line-adjustment indicator.\|CIP239-0002\| \|CLT191\|LINE-NUM-ADJ\|This field should be left blank or space-filled if the ADJUSTMENT-INDICATOR = 0. Otherwise, if there is a line adjustment indicator, then there should be a line adjustment number.\|CLT191-0002\| \|CLT192\|LINE-ADJUSTMENT-IND\|If there is a line adjustment number, then there must be a line-adjustment indicator.\|CLT192-0002\| \|CLT192\|LINE-ADJUSTMENT-IND\|If there is a line adjustment reason, then there must be a line adjustment indicator.\|CLT192-0003 \|COT161\|LINE-NUM-ADJ\|This field should be left blank or space-filled if the ADJUSTMENT-INDICATOR = 0. Otherwise, if there is a line adjustment indicator, then there should be a line adjustment number.\|COT161-0002\| \|COT162\|LINE-ADJUSTMENT-IND\|If there is a line adjustment number, then there must be a line-adjustment indicator.\|COT162-0002\| \|COT162\|LINE-ADJUSTMENT-IND\|If there is a line adjustment reason, then there must be a line adjustment indicator.\|COT162-003\| \|CRX115\|LINE-NUM-ADJ\|This field should be 8-filled, left blank or space-filled if the ADJUSTMENT-INDICATOR = 0. Otherwise, if there is a line adjustment indicator, then there should be a line adjustment number.\|CRX115-002\| \|CRX116\|LINE-ADJUSTMENT-IND\|If there is a line adjustment number, then there must be a line-adjustment indicator.\|CRX116-002\|	\|DE No\|Data Element Name\|Coding Requirement\|CR No\| \|CIP238\|LINE-NUM-ADJ\|This field should be left blank or space-filled if the ADJUSTMENT-INDICATOR = 0.\|Not Applicable\| \|CIP239\|LINE-ADJUSTMENT-IND\|Not Applicable.\|CIP239-0002\| \|CLT191\|LINE-NUM-ADJ\|This field should be left blank or space-filled if the ADJUSTMENT-INDICATOR = 0.\|CLT191-0002\| \|CLT192\|LINE-ADJUSTMENT-IND\|Not Applicable.\|CLT192-0002\| \|CLT192\|LINE-ADJUSTMENT-IND\|Not Applicable.\|CLT192-0003 \|COT161\|LINE-NUM-ADJ\|This field should be left blank or space-filled if the ADJUSTMENT-INDICATOR = 0.\|COT161-0002\| \|COT162\|LINE-ADJUSTMENT-IND\|Not Applicable.\|COT162-0002\| \|COT162\|LINE-ADJUSTMENT-IND\|Not Applicable.\|COT162-003\| \|CRX115\|LINE-NUM-ADJ\|This field should be 8-filled, left blank or space-filled if the ADJUSTMENT-INDICATOR = 0.\|CRX115-002\| \|CRX116\|LINE-ADJUSTMENT-IND\|Not Applicable.\|CRX116-002\|
11/23/2018	2.3.0	ADJUSTMENT-IND	UPDATE	Data Dictionary - Valid Values	N/A	Valid values for ADJUSTMENT-IND has been updated per T-MSIS DD 2.1. As per DD 2.1 the Valid values are: 0 Original Claim/Encounter/Payment 1 Void/Reversal/Cancel of a prior submission 4 Replacement/Resubmission of a previously paid/approved claim/encounter/payment 5 Credit Gross Adjustment 6 Debit Gross Adjustment