An official website of the United States government

Official websites use .gov
A .gov website belongs to an official government organization in the United States.

Secure .gov websites use HTTPS
A lock () or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites.

TMSIS Dataguide Medicaid.gov
Version 3.27.0

CLAIM-LINE-RECORD-RX

File Segment

File Segment Number

CRX00003

File Name

CRX - CLAIM PHARMACY

Last updated

No Updates

Data Elements Reference
DE Number System DE Number Data Element Definition Valid Values
CRX108 CRX.003.108 RECORD-ID The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). CRX108 Values
CRX109 CRX.003.109 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. CRX109 Values
CRX110 CRX.003.110 RECORD-NUMBER

A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file.

 N/A
CRX111 CRX.003.111 MSIS-IDENTIFICATION-NUM

A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572

 N/A
CRX112 CRX.003.112 ICN-ORIG A unique number assigned by the state's payment system that identifies an original or adjustment claim. N/A
CRX113 CRX.003.113 ICN-ADJ

A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction.

 N/A
CRX114 CRX.003.114 LINE-NUM-ORIG A unique number to identify the transaction line number that is being reported on the original claim. N/A
CRX115 CRX.003.115 LINE-NUM-ADJ A unique number to identify the transaction line number that identifies the line number on the adjustment claim. N/A
CRX116 CRX.003.116 LINE-ADJUSTMENT-IND

A code to indicate the type of adjustment record claim/encounter represents at claim detail level.

 CRX116 Values
CRX117 CRX.003.117 LINE-ADJUSTMENT-REASON-CODE Claim adjustment reason codes communicate why a service line was paid differently than it was billed. CRX117 Values
CRX118 CRX.003.118 SUBMITTER-ID The Submitter Identification number is the value that identifies the provider/trading partner/clearing house organization to the state's claim adjudication system. N/A
CRX119 CRX.003.119 CLAIM-LINE-STATUS The claim line status codes from the 277 transaction set identify the status of a specific detail claim line rather than the entire claim. Only report the claim line for the final, adjudicated claim. CRX119 Values
CRX120 CRX.003.120 NATIONAL-DRUG-CODE

A code following the National Drug Code format indicating the drug, device, or medical supply covered by this claim.

 N/A
CRX121 CRX.003.121 BILLED-AMT

The amount billed at the claim detail level as submitted by the provider. For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed the managed care plan.

For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the provider billed the sub-capitated entity 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.

 N/A
CRX122 CRX.003.122 ALLOWED-AMT

The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed care encounters the Allowed Amount is determined by the managed care organization.

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 allowed 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.

 N/A
CRX123 CRX.003.123 BENEFICIARY-COPAYMENT-PAID-AMOUNT

The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on a claim line. Do not include copayment payments made by a third party/ies on behalf of the beneficiary. This is a copayment paid for a service in the corresponding claim line for OT and RX claim files. The Beneficiary Copayment Paid Amount is an optional line level data element reported for OT and RX claim file types, only. If the beneficiary copayment paid amount is not available at the claim line level, report the total copayment paid amount in the header level copayment data element.

 N/A
CRX124 CRX.003.124 TPL-AMT Third-party liability refers to the legal obligation of third parties, i.e., certain individuals, entities, or programs, to pay all or part of the expenditures for medical assistance furnished under a state plan. This is the total amount denoted at the claim detail level paid by the third party. N/A
CRX125 CRX.003.125 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.

 N/A
CRX126 CRX.003.126 MEDICAID-FFS-EQUIVALENT-AMT

The amount that would have been paid had the services been provided on a Fee for Service basis.

 N/A
CRX127 CRX.003.127 MEDICARE-DEDUCTIBLE-AMT

The amount paid by Medicaid/CHIP on this claim at the claim line level toward the beneficiary's Medicare deductible. If the Medicare deductible amount can be identified separately from Medicare coinsurance payments, code that amount in this field. If the Medicare coinsurance and deductible payments cannot be separated, fill this field with the combined payment amount and Medicare Coinsurance Payment is not required.

 N/A
CRX128 CRX.003.128 MEDICARE-COINS-AMT The amount paid by Medicaid/CHIP on this claim toward the recipient's Medicare coinsurance at the claim detail level. If the Medicare coinsurance amount can be identified separately from Medicare deductible payments, code that amount in this field. If Medicare coinsurance and deductible payments cannot be separated, populate the Medicare Deductible Amount. N/A
CRX129 CRX.003.129 MEDICARE-PAID-AMT

The amount paid by Medicare on this claim. For claims where Medicare payment is only available at the header level, report the entire payment amount on the T-MSIS claim line with the highest charge or the 1st non-denied line. Zero fill Medicare Paid Amount on all other claim lines.

 N/A
CRX131 CRX.003.131 PRESCRIPTION-QUANTITY-ALLOWED The maximum allowable quantity of a drug or service that may be dispensed per prescription per date of service or per month. Quantity limits are applied to medications when the majority of appropriate clinical utilizations will be addressed within the quantity allowed. For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMLT claims/encounter records, use the Revenue Center Quantity Actual field. One prescription for 100 250 milligram tablets results in Prescription Quantity Allowed =100. N/A
CRX132 CRX.003.132 PRESCRIPTION-QUANTITY-ACTUAL The quantity of a drug that is dispensed for a prescription as reported ny National Drug Code on the claim line. For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMLT claims/encounter records, use the Revenue Center Quantity Actual field. N/A
CRX133 CRX.003.133 UNIT-OF-MEASURE A code to indicate the basis by which the quantity of the drug or supply is expressed. CRX133 Values
CRX134 CRX.003.134 TYPE-OF-SERVICE

A code to categorize the services provided to a Medicaid or CHIP enrollee.

 CRX134 Values
CRX135 CRX.003.135 HCBS-SERVICE-CODE A code to indicate that the service represents a long-term care home and community based service or support for an individual with chronic medical and/or mental conditions. The codes help to delineate between acute care and long-term care provided in the home and community setting (e.g. 1915(c), 1915(i), 1915(j), and 1915(k) services). CRX135 Values
CRX136 CRX.003.136 HCBS-TAXONOMY A code to classify the home and community based services listed on the claim into the HCBS taxonomy. CRX136 Values
CRX137 CRX.003.137 OTHER-TPL-COLLECTION This data element indicates that the claim is for a beneficiary for whom other third party resource development and collection activities are in progress, when the liability is not another health insurance plan for which the eligible is a beneficiary. CRX137 Values
CRX138 CRX.003.138 DAYS-SUPPLY Number of days supply dispensed. N/A
CRX139 CRX.003.139 NEW-REFILL-IND Indicator showing whether the prescription being filled was a new prescription or a refill. If it is a refill, the indicator will indicate the number of refills. CRX139 Values
CRX140 CRX.003.140 BRAND-GENERIC-IND Indicates whether the drug is a brand name, generic, single-source, or multi-source drug. CRX140 Values
CRX141 CRX.003.141 DISPENSE-FEE-SUBMITTED The charge to cover the cost of the professional dispensing fee for the prescription. N/A
CRX142 CRX.003.142 PRESCRIPTION-NUM The unique identification number assigned by the pharmacy or supplier to the prescription. N/A
CRX143 CRX.003.143 DRUG-UTILIZATION-CODE

A code indicating the conflict, intervention and outcome of a prescription presented for fulfillment. The T-MSIS Drug Utilization Code data element is composite field comprised of three distinct NCPDP data elements: "Reason for Service Code" (439-E4); "Professional Service Code" (440-E5); and "Result of Service Code" (441-E6). All 3 of these NCPDP fields are situationally required and independent of one another. Pharmacists may report none, one, two or all three. NCPDP situational rules call for one or more of these values in situations where the field(s) could result in different coverage, pricing, patient financial responsibility, drug utilization review outcome, or if the information affects payment for, or documentation of, professional pharmacy service. The NCPDP "Reasons of Service Code" (bytes 1 & 2 of the T-MSIS DRUG-UTILIZATION-CODE) explains whether the pharmacist filled the prescription, filled part of the prescription, etc. The NCPDP "Professional Service Code" (bytes 3 & 4 of the T-MSIS Drug Utilization Code) describes what the pharmacist did for the patient. The NCPDP "Result of Service Code" (bytes 5 & 6 of the T-MSIS Drug Utilization Code) describes the action the pharmacist took in response to a conflict or the result of a pharmacist's professional service. Because the T-MSIS Drug Utilization Code data element is a composite field, it is necessary for the state to populate all six bytes if any of the three NCPDP fields has a value. In such situations, use 'spaces' as placeholders for not applicable codes.

 CRX143 Values
CRX144 CRX.003.144 DTL-METRIC-DEC-QTY Metric decimal quantity of the product with the appropriate unit of measure (each, gram, or milliliter). N/A
CRX145 CRX.003.145 COMPOUND-DOSAGE-FORM The physical form of a dose of medication, such as a capsule or injection. CRX145 Values
CRX146 CRX.003.146 REBATE-ELIGIBLE-INDICATOR An indicator to identify claim lines with an NDC that is eligible for the drug rebate program. CRX146 Values
CRX147 CRX.003.147 IMMUNIZATION-TYPE [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] CRX147 Values
CRX148 CRX.003.148 BENEFIT-TYPE The benefit category corresponding to the service reported on the claim or encounter record. Note: The code definitions in the valid value list originate from the Medicaid and CHIP Program Data System (MACPro) benefit type list. See Appendix H: Benefit Types CRX148 Values
CRX149 CRX.003.149 CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT A code to indicate the Federal funding source for the payment. CRX149 Values
CRX150 CRX.003.150 XIX-MBESCBES-CATEGORY-OF-SERVICE

A code indicating the category of service for the paid claim. The category of service is the line item from the CMS-64 form that states use to report their expenditures and request federal financial participation.

 CRX150 Values
CRX151 CRX.003.151 XXI-MBESCBES-CATEGORY-OF-SERVICE

A code to indicate the category of service for the paid claim. The category of service is the line item from the CMS-21 form that states use to report their expenditures and request federal financial participation.

 CRX151 Values
CRX152 CRX.003.152 OTHER-INSURANCE-AMT The amount paid by insurance other than Medicare or Medicaid on this claim. N/A
CRX153 CRX.003.153 STATE-NOTATION

A free text field for the submitting state to enter whatever information it chooses.

 N/A
CRX157 CRX.003.157 ADJUDICATION-DATE The date on which the payment status of the claim was finally adjudicated by the state. For Encounter Records (Type of Claim = 3, C, W), use date the encounter was processed by the state. N/A
CRX158 CRX.003.158 SELF-DIRECTION-TYPE This data element is not applicable to this file type. CRX158 Values
CRX159 CRX.003.159 PRE-AUTHORIZATION-NUM A number, code or other value that indicates the services provided on this claim have been authorized by the payee or other service organization, or that a referral for services has been approved. (Also referred to as a Prior Authorization or Referral Number). N/A
CRX167 CRX.003.167 INGREDIENT-COST-SUBMITTED The charge to cover the cost of ingredients for the prescription or drug. N/A
CRX168 CRX.003.168 INGREDIENT-COST-PAID-AMT The amount paid by Medicaid or the managed care plan on this claim or adjustment at the claim detail level towards the cost of ingredients for the prescription or drug. N/A
CRX169 CRX.003.169 DISPENSE-FEE-PAID-AMT The amount paid by Medicaid or the managed care plan on this claim or adjustment towards the cost of the pharmacy's professional dispensing fee for the prescription. N/A
CRX170 CRX.003.170 PROFESSIONAL-SERVICE-FEE-SUBMITTED The charge to cover the clinical services, not otherwise covered under the professional dispensing fee. (Example - not filling a prescription because of therapeutic duplication). N/A
CRX171 CRX.003.171 PROFESSIONAL-SERVICE-FEE-PAID-AMT The amount paid by Medicaid or the managed care plan on this claim or adjustment towards the costs of clinical services not otherwise covered under the professional dispensing fee. N/A
CRX172 CRX.003.172 IHS-SERVICE-IND

To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes.

 CRX172 Values
Definition
A record to capture data about specific prescription goods or services rendered to a Medicaid/CHIP enrollee.

File Segment Length
1450