CRX.002.041

TOT-MEDICAID-PAID-AMT

Data Element

DE Number

CRX041

System DE Number

CRX.002.041

File Name

CRX - CLAIM PHARMACY

File Segment Number

CRX00002

File Segment Name

CLAIM-HEADER-RECORD-RX

Last updated

09/12/2024

Overview Valid Values Related Rules Related DQ Measures Other Instances

Definition	The total amount paid to the provider by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider.
Size	S9(11)V99
FLF Start Position	254
FLF Stop Position	266
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 (eg. 100.50) 3. Must have an associated Medicaid Paid Date 4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount 5. When Payment Level Indicator equals "2", value must equal the sum of line level Medicaid Paid Amounts 6. Conditional 7. Value must be populated, when Type of Claim is in [1,A] 8. Value must not be populated or equal to ‘0.00’ when associated Claim Status is in [26,026,87,087,542,585,654] 9. Value should not be populated, when associated Type of Claim value is in [4,D]

Valid Value Code Set	Valid Value Code	Valid Value Name	Valid Value Description	Effective Start Date	Effective End Date
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RULE ID	RULE Definition
RULE-1792	If a claim is a non-denied claim from an RX file, then the total Medicaid paid amount value reported must be a valid dollar amount that matches the specified T-MSIS picture format: S9(11)V99.
RULE-7272	If a claim is a non-denied claim from an RX file that is an original claim and is a separate CHIP FFS, Medicaid or Medicaid-expansion FFS claim, with a crossover indicator equal to 0 or null, then the total medicaid paid amount must be populated.
RULE-7281	If a claim is a non-denied claim from an RX file that is an original claim and is a Medicaid or Medicaid-expansion CHIP, Medicaid or Medicaid-expansion CHIP encounter, separate CHIP FFS or encounter claim, and the payment level indicator is for line, then the sum of the claim line medicaid paid amount is equal to the claim header total medicaid paid amount
RULE-7438	If the non-denied claim is an RX file, and is an Medicaid-SCHIP or Separate CHIP service tracking claim, then the claim has a null value or 0.00 value for total medicaid paid amount.
RULE-7568	If an RX claim header is for a denied claim, then total medicaid paid amount has a missing or zero value.
RULE-7685	If a claim is a non-denied claim from an RX file that is an original claim and is a Medicaid or Medicaid-expansion CHIP encounter, separate CHIP encounter claim, and the payment level indicator is for line, then the sum of the claim line medicaid paid amount is equal to the claim header total medicaid paid amount.
RULE-7793	If a claim is a non-denied claim from an RX file that is an original claim and is a Medicaid or Medicaid-expansion CHIP or Separate CHIP Fee-for-Service claim, and the payment level indicator is for line, then the sum of the claim line medicaid paid amount is equal to the claim header total medicaid paid amount.

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Measure ID	Measure Name
EXP-16-001-13	Sum of Total Medicaid Paid Amount
EXP-16-002-14	Total paid for TYPE-OF-SERVICE = 11 (Family planning services and supplies for individuals of child-bearing age)
EXP-16-003-16	Total paid for TYPE-OF-SERVICE = 18 (Home health services - Medical supplies, equipment, and appliances suitable for use in the home)
EXP-16-004-17	Total paid for TYPE-OF-SERVICE = 33 (Prescribed drugs)
EXP-16-005-18	Total paid for TYPE-OF-SERVICE = 34 (Over-the-counter medications.)
EXP-16-006-19	Total paid for TYPE-OF-SERVICE = 36 (Medical equipment/prosthetic devices)
EXP-16-007-20	Total paid for TYPE-OF-SERVICE = 85 (Prenatal care and pre-pregnancy family planning services and supplies.)
EXP-16-008-21	Total paid for TYPE-OF-SERVICE = 89 (Disposable medical supplies.)
EXP-16-009-15	Total paid for TYPE-OF-SERVICE = 127 (Indian Health Service (IHS) - Family Plan)
EXP-16-010-1	% of claim headers with Total Medicaid Paid Amount > $300,000
EXP-16-011-4	Average Total Medicaid Paid Amount (excludes outliers with Total Medicaid Paid Amount > $300,000)
EXP-16-012-5	Average paid per record for TYPE-OF-SERVICE = 11 (Family planning services and supplies for individuals of child-bearing age)
EXP-16-013-7	Average paid per record for TYPE-OF-SERVICE = 18 (Home health services - Medical supplies, equipment, and appliances suitable for use in the home)
EXP-16-014-8	Average paid per record for TYPE-OF-SERVICE = 33 (Prescribed drugs)
EXP-16-015-9	Average paid per record for TYPE-OF-SERVICE = 34 (Over-the-counter medications.)
EXP-16-016-10	Average paid per record for TYPE-OF-SERVICE = 36 (Medical equipment/prosthetic devices)
EXP-16-017-11	Average paid per record for TYPE-OF-SERVICE = 85 (Prenatal care and pre-pregnancy family planning services and supplies)
EXP-16-018-12	Average paid per record for TYPE-OF-SERVICE = 89 (Disposable medical supplies)
EXP-16-019-6	Average paid per record for TYPE-OF-SERVICE = 127 (Indian Health Service (IHS) - Family Plan)
EXP-16-021-3	% of claim headers with Total Medicaid Paid Amount = $0 or missing
EXP-17-001-9	Total paid for TYPE-OF-SERVICE = 11 (Family planning services and supplies for individuals of child-bearing age)
EXP-17-002-11	Total paid for TYPE-OF-SERVICE = 18 (Home health services - Medical supplies, equipment, and appliances suitable for use in the home)
EXP-17-003-12	Total paid for TYPE-OF-SERVICE = 33 (Prescribed drugs)
EXP-17-004-13	Total paid for TYPE-OF-SERVICE = 34 (Over-the-counter medications.)
EXP-17-005-14	Total paid for TYPE-OF-SERVICE = 36 (Medical equipment/prosthetic devices)

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DE Number	System DE Number	DE Name	File Segment Number	File Segment Name
CIP114	CIP.002.114	TOT-MEDICAID-PAID-AMT	CIP00002	CLAIM-HEADER-RECORD-IP
CLT065	CLT.002.065	TOT-MEDICAID-PAID-AMT	CLT00002	CLAIM-HEADER-RECORD-LT
COT050	COT.002.050	TOT-MEDICAID-PAID-AMT	COT00002	CLAIM-HEADER-RECORD-OT

Published Date	Data Guide Version	Data Element	Action	Field	Before	After
09/12/2024	3.29.0	CRX.002.041	UPDATE	Definition	The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider.	The total amount paid to the provider by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider.
09/12/2024	3.29.0	CRX.002.041	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. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must be populated, when Type of Claim is in [‘1’, ‘A’]8. Value must not be populated or equal to ‘0.00’ when associated Claim Status is in ['26', '026', '87', '087', '542', '585', '654']9. Value should not be populated, when associated Type of Claim value is in [‘4’, ‘D’]	1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (eg. 100.50)3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals "2", value must equal the sum of line level Medicaid Paid Amounts6. Conditional7. Value must be populated, when Type of Claim is in [1,A]8. Value must not be populated or equal to ‘0.00’ when associated Claim Status is in [26,026,87,087,542,585,654]9. Value should not be populated, when associated Type of Claim value is in [4,D]
08/28/2023	3.12.0	CRX.002.041	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. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. 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. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must be populated, when Type of Claim is in [‘1’, ‘A’]8. Value must not be populated or equal to ‘0.00’ when associated Claim Status is in ['26', '026', '87', '087', '542', '585', '654']9. Value should not be populated, when associated Type of Claim value is in [‘4’, ‘D’]
08/09/2023	3.11.0	CRX.002.041	UPDATE	Definition	The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim.	The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider.
07/15/2022	3.0.1	CRX041	UPDATE	Data Dictionary	DE NO\| DATA ELEMENT NAME COMPUTING\|DEFINITION CRX041\|TOT-MEDICAID-PAID-AMT\|The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim.	DE NO\| DATA ELEMENT NAME COMPUTING\|DEFINITION CRX041\|TOT-MEDICAID-PAID-AMT\|The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. 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.