CRX.002.044

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TMSIS Dataguide

Medicaid.gov

Version 3.36.0

TOT-MEDICARE-COINS-AMT

Data Element

DE Number

CRX044

System DE Number

CRX.002.044

File Name

CRX - CLAIM PHARMACY

File Segment Number

File Segment Name

CLAIM-HEADER-RECORD-RX

Last updated

Overview Valid Values Related Rules Related DQ Measures Other Instances

Definition	The total amount paid by the Medicaid/CHIP agency or a managed care plan towards the portion of the Medicare allowed charges that Medicare applied to coinsurance.
Size	S9(11)V99
FLF Start Position	280
FLF Stop Position	292
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. If associated Crossover Indicator value is "0" (not a crossover claim), then value should not be populated 4. Conditional 5. If associated Medicare Combined Deductible Indicator is "1", then value must not be populated 6. When populated, value must be less than or equal to Total Billed Amount

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

RULE ID	RULE Definition
RULE-1797	If a claim is a non-denied claim from an RX file, then the total Medicare coinsurance amount value reported must be a valid dollar amount that matches the specified T-MSIS picture format: S9(11)V99.
RULE-1798	If the total Medicare coinsurance amount and total billed amount are populated and greater than zero on a non-denied claim from an RX file, then the total Medicare coinsurance amount value reported must be less than or equal to the total billed amount value
RULE-1801	If a claim is a non-denied claim from an RX file, and the medicare combined deductible indicator is equal to '1', then the total medicare coinsurance amount must be 0 or null.
RULE-7660	If a claim is a non-denied, crossover Medicaid Encounter, original or adjustment paid claim from an RX file, then the claim must have a non-null value and not zero value for medicare paid amount or total medicare coinsurance amount or total medicare deductible amount.
RULE-7665	If a claim is a non-denied, non-crossover Medicaid Encounter, original or adjustment paid claim from an RX file, then the claim must have a null value or zero value for medicare paid amount, total medicare coinsurance amount and total medicare deductible amount.
RULE-7777	If a claim is a non-denied, crossover Medicaid or M-CHIP or Separate CHIP Fee-for-Service, original or adjustment paid claim from an RX file, then the claim must have a non-null value and not zero value for medicare paid amount or total medicare coinsurance amount or total medicare deductible amount.
RULE-7781	If a claim is a non-denied, non-crossover Medicaid or M-CHIP or Separate CHIP Fee-for-Service, original or adjustment paid claim from an RX file, then the claim must have a null value or zero value for medicare paid amount, total medicare coinsurance amount and total medicare deductible amount.
RULE-7839	If a claim is a non-denied, non-crossover Medicaid or M-CHIP or Separate CHIP Supplemental, original or adjustment paid claim from an RX file, then the claim must have a null value or zero value for medicare paid amount, total medicare coinsurance amount and total medicare deductible amount.
RULE-7843	If a claim is a non-denied, non-crossover Medicaid or M-CHIP or Separate CHIP Service Tracking, original or adjustment paid claim from an RX file, then the claim must have a null value or zero value for medicare paid amount, total medicare coinsurance amount and total medicare deductible amount.

Measure ID	Measure Name
FFS-46-001-1	% of crossover claim headers where Total Medicare Deductible Amount and Total Medicare Coinsurance Amount do not sum to Total Medicaid Paid Amount
FFS-53-004-4	% of non-crossover claim headers where MEDICARE-PAID-AMT, TOT-MEDICARE-COINS-AMT, or TOT-MEDICARE-DEDUCTIBLE-AMT is non-zero
FFS-54-004-4	% of crossover claim headers where MEDICARE-PAID-AMT, TOT-MEDICARE-COINS-AMT, and TOT-MEDICARE-DEDUCTIBLE-AMT are 0 or missing
MCR-63-004-4	% of non-crossover claim headers where MEDICARE-PAID-AMT, TOT-MEDICARE-COINS-AMT, or TOT-MEDICARE-DEDUCTIBLE-AMT is non-zero
MCR-64-004-4	% of crossover claim headers where MEDICARE-PAID-AMT, TOT-MEDICARE-COINS-AMT, and TOT-MEDICARE-DEDUCTIBLE-AMT are 0 or missing
MIS-8-029-29	% missing: TOT-MEDICARE-COINS-AMT (CRX00002)
MIS-27-029-29	% missing: TOT-MEDICARE-COINS-AMT (CRX00002)
MIS-85-029-29	% missing: TOT-MEDICARE-COINS-AMT (CRX00002)
FFS-54-004_1-8	% of crossover claim headers where MEDICARE-PAID-AMT, TOT-MEDICARE-COINS-AMT, and TOT-MEDICARE-DEDUCTIBLE-AMT are 0 or missing
MCR-64-004_1-8	% of crossover claim headers where MEDICARE-PAID-AMT, TOT-MEDICARE-COINS-AMT, and TOT-MEDICARE-DEDUCTIBLE-AMT are 0 or missing
RULE-7665	% of non-crossover encounter claims where MEDICARE-PAID-AMT, TOT-MEDICARE-COINS-AMT, or TOT-MEDICARE-DEDUCTIBLE-AMT is non-zero
RULE-7777	% of crossover claims where MEDICARE-PAID-AMT, TOT-MEDICARE-COINS-AMT, and TOT-MEDICARE-DEDUCTIBLE-AMT are 0 or missing
RULE-7781	% of non-crossover claims where MEDICARE-PAID-AMT, TOT-MEDICARE-COINS-AMT, or TOT-MEDICARE-DEDUCTIBLE-AMT is non-zero

DE Number	System DE Number	DE Name	File Segment Number	File Segment Name
CIP117	CIP.002.117	TOT-MEDICARE-COINS-AMT	CIP00002	CLAIM-HEADER-RECORD-IP
CLT068	CLT.002.068	TOT-MEDICARE-COINS-AMT	CLT00002	CLAIM-HEADER-RECORD-LT
COT053	COT.002.053	TOT-MEDICARE-COINS-AMT	COT00002	CLAIM-HEADER-RECORD-OT

Published Date	Data Guide Version	Data Element	Action	Field	Before	After
09/12/2024	3.29.0	CRX.002.044	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. If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated.4. Conditional5. If associated Medicare Combined Deductible Indicator is '1', then value must not be populated6. When populated, value must be less than or equal to Total Billed Amount	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. If associated Crossover Indicator value is "0" (not a crossover claim), then value should not be populated4. Conditional5. If associated Medicare Combined Deductible Indicator is "1", then value must not be populated6. When populated, value must be less than or equal to Total Billed Amount