CRX.003.125

MEDICAID-PAID-AMT

Data Element

DE Number

CRX125

System DE Number

CRX.003.125

File Name

CRX - CLAIM PHARMACY

File Segment Number

CRX00003

File Segment Name

CLAIM-LINE-RECORD-RX

Last updated

Overview Valid Values Related Rules Related DQ Measures Other Instances

Definition	The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. 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 paid the provider 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	225
FLF Stop Position	237
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

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

RULE ID	RULE Definition
RULE-1928	If a claim line is a non-denied claim line from an RX file, then the Medicaid paid amount value reported must be a valid dollar amount that matches the specified T-MSIS picture format: S9(11)V99.
RULE-7563	If an RX claim line is for a denied claim, then the medicaid paid amount has a missing or zero value.

Measure ID	Measure Name
MCR-18-010-11	Ratio of Average FFS Equivalent to Average Paid for TYPE-OF-SERVICE = 18 (Home health services - Medical supplies, equipment, and appliances suitable for use in the home)
RULE-7793	% of claim headers with PAYMENT-LEVEL-IND = 2 where the sum of Medicaid Paid Amount from the lines does not equal Total Medicaid Paid Amount from the header
MCR-59R-004-16	% of Plan IDs over the threshold for MCR-59P-004-16 (% of claim headers with PAYMENT-LEVEL-IND = 2 where the sum of Medicaid Paid Amount from the lines does not equal Total Medicaid Paid Amount from the header, by Plan ID)
MCR-59P-004-16	% of claim headers with PAYMENT-LEVEL-IND = 2 where the sum of Medicaid Paid Amount from the lines does not equal Total Medicaid Paid Amount from the header, by Plan ID
MCR-59-004-4	% of claim headers where the sum of Medicaid Paid Amount from the lines does not equal Total Medicaid Paid Amount from the header
MCR-18-016-10	Ratio of Average FFS Equivalent to Average Paid for TYPE-OF-SERVICE = 127 (Indian Health Service (IHS) - Family Plan)
MCR-18-015-16	Ratio of Average FFS Equivalent to Average Paid for TYPE-OF-SERVICE = 89 (Disposable medical supplies.)
MCR-18-014-15	Ratio of Average FFS Equivalent to Average Paid for TYPE-OF-SERVICE = 85 (Prenatal care and pre-pregnancy family planning services and supplies.)
MCR-18-013-14	Ratio of Average FFS Equivalent to Average Paid for TYPE-OF-SERVICE = 36 (Medical equipment/prosthetic devices)
MCR-18-012-13	Ratio of Average FFS Equivalent to Average Paid for TYPE-OF-SERVICE = 34 (Over-the-counter medications.)
MCR-18-011-12	Ratio of Average FFS Equivalent to Average Paid for TYPE-OF-SERVICE = 33 (Prescribed drugs)
FFS-49-004-16	% of claim headers with PAYMENT-LEVEL-IND = 2 where the sum of Medicaid Paid Amount from the lines does not equal Total Medicaid Paid Amount from the header
MCR-18-009-9	Ratio of Average FFS Equivalent to Average Paid for TYPE-OF-SERVICE = 11 (Family planning services and supplies for individuals of child-bearing age)
FFS-49-004-4	% of claim headers where the sum of Medicaid Paid Amount from the lines does not equal Total Medicaid Paid Amount from the header
RULE-7563	% of denied claim lines where Medicaid Paid Amount is non-missing and non-zero
MIS-86-012-12	% missing: MEDICAID-PAID-AMT (CRX00003)
MIS-28-013-13	% missing: MEDICAID-PAID-AMT (CRX00003)
MIS-9-014-14	% missing: MEDICAID-PAID-AMT (CRX00003)
MCR-59-012-12	% of claim lines with PAYMENT-LEVEL-IND=2 (claim detail) that have Medicaid Paid Amount greater than a non-zero Allowed Amount
MCR-59-004-16	% of claim headers with PAYMENT-LEVEL-IND = 2 where the sum of Medicaid Paid Amount from the lines does not equal Total Medicaid Paid Amount from the header
FFS-49-012-12	% of claim lines with PAYMENT-LEVEL-IND=2 (claim detail) that have Medicaid Paid Amount greater than a non-zero Allowed Amount

DE Number	System DE Number	DE Name	File Segment Number	File Segment Name
CIP254	CIP.003.254	MEDICAID-PAID-AMT	CIP00003	CLAIM-LINE-RECORD-IP
CLT208	CLT.003.208	MEDICAID-PAID-AMT	CLT00003	CLAIM-LINE-RECORD-LT
COT178	COT.003.178	MEDICAID-PAID-AMT	COT00003	CLAIM-LINE-RECORD-OT

Published Date	Data Guide Version	Data Element	Action	Field	Before	After
08/09/2023	3.11.0	CRX.003.125	UPDATE	Definition	The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.	The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.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 paid the provider 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.
08/09/2023	3.11.0	CRX.003.125	UPDATE	Last update date	12/08/2022	8/9/2023
09/11/2020	2.4.0	CIP254, CLT208, COT178, CRX125	UPDATE	Data Dictionary	Current Coding Requirement: For claims where Medicaid payment is only available at the header level, report the entire payment amount on the MSIS record corresponding to the line item with the highest charge. Zero fill Medicaid Amount Paid on all other MSIS records created from the original claim.	Proposed Coding requirement: For claims where Medicaid payment is only available at the header level, report the entire payment amount on the MSIS record corresponding to the line item with the highest charge or the 1st detail. Zero fill Medicaid Amount Paid on all other MSIS records created from the original claim.
08/13/2021	3.0.0	MEDICAID-PAID-AMT	UPDATE	Data Dictionary	\|Definition\| \|The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. For claims where Medicaid payment is only available at the header level, report the entire payment amount on the T-MSIS record corresponding to the line item with the highest charge or the 1st detail. Zero fill Medicaid Amount Paid on all other MSIS records created from the original claim.\|	\|Definition\| \|The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.\|
07/15/2022	3.0.1	CRX125	UPDATE	Data Dictionary	DE NO\| DATA ELEMENT NAME COMPUTING\|DEFINITION CRX125\|MEDICAID-PAID-AMT\|The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.	DE NO\| DATA ELEMENT NAME COMPUTING\|DEFINITION CRX125\|MEDICAID-PAID-AMT\|The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. 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 paid the provider 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.