CRX.002.031

CLAIM-STATUS-CATEGORY

Data Element

DE Number

CRX031

System DE Number

CRX.002.031

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	The general category of the claim status (accepted, rejected, pended, finalized, additional information requested, etc.) from the 277 transaction set which is then further detailed in the companion data element claim status.
Size	X(3)
FLF Start Position	180
FLF Stop Position	182
Segment Key Field Identifier	Not Applicable
Coding Requirements	1. Value must be in Claim Status Category List (VVL) 2. (Denied Claim) if associated Claim Denied Indicator indicates the claim was denied, then value must be "F2" 3. (Denied Claim) if associated Claim Status is in [ 542, 585, 654 ], then value must be "F2" 4. Value must be 3 characters or less 5. Mandatory

This data element's valid value code set is maintained by a Code Set Maintenance Organization (CSMO), the official licensing organization for specific valid value code sets. The CSMO is the system of record for those specific valid value code sets. While T-MSIS endeavors to be in-sync with CMSO's updates, minor delays may occur but that shouldn't block T-MSIS data submissions using the CSMO's latest version.

Link to Claim Status Category List

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

RULE ID	RULE Definition
RULE-1771	If the claim status category is populated on a non-denied claim from an RX file, then the claim status category reported must be found in the list of valid values.
RULE-6597	If a claim is a non-denied claim from an RX file, then the claim status category reported must be compatible with specified T-MSIS picture format: X(3).
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-7549	If the 1115A demonstration indicator is equal to 1 (yes) on a non-denied claim from an RX file, and the prescription fill date is within the 1115A effective and end dates, then the 1115A demonstration indicator value reported on the 1115A demonstration information segment must be populated with a 1 value.
RULE-7636	All non-denied, paid RX claim header records must have a corresponding non-denied claim line record.
RULE-7773	If a claim is a non-denied claim from an RX file, and the waiver type is populated, and the claim prescription fill date is between the waiver enrollment effective and end dates, then the claim waiver type is equal to the waiver participation waiver type.
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-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'

Measure ID	Measure Name

DE Number	System DE Number	DE Name	File Segment Number	File Segment Name
CIP103	CIP.002.103	CLAIM-STATUS-CATEGORY	CIP00002	CLAIM-HEADER-RECORD-IP
CLT055	CLT.002.055	CLAIM-STATUS-CATEGORY	CLT00002	CLAIM-HEADER-RECORD-LT
COT040	COT.002.040	CLAIM-STATUS-CATEGORY	COT00002	CLAIM-HEADER-RECORD-OT