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 to the provider 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