Recipient indicator (MAX TOS 37)

SAS Name
FEE_FOR_SRVC_IND_37

INDICATOR TO SHOW IF AND HOW THE ELIGIBLE RECEIVED A MEDICAID SERVICE (UNDER FEE-FOR-SERVICE) DURING THE CALENDAR YEAR, FOR THIS TYPE OF SERVICE. THIS DATA ELEMENT IS REPORTED FOR ALL TYPES OF SERVICE, EXCEPT TOS = 20, 21, 22, AND 23.

Comments

USER NOTE: SEE 'RECIPIENT INDICATOR' WHICH IS SIMILAR TO 'TYPE OF SERVICE RECIPIENT INDICATOR'. THIS ELEMENT IS DIFFERENT IN THAT IT IS CREATED BY TYPE OF SERVICE, FOR EACH OF THE LISTED TYPES OF SERVICES AND IT DOES NOT INCLUDE CODE VALUES FOR PREMIUM PAYMENTS. SOURCE MSIS FILES CONTAIN RECORDS WITH MEDICAID PAYMENT AMOUNT = $0 IF THE SERVICE WAS COVERED, BUT FULL PAYMENT WAS MADE BY ANOTHER PAYER (E.G. THIRD PARTY LIABILITY). THERE ARE ALSO INSTANCES OF CLAIMS WITH MEDICAID PAID AMOUNT < $0. IN MAX ALL NON-ENCOUNTER CLAIMS WITH MEDICAID PAYMENT AMOUNT LESS THAN OR EQUAL TO ZERO ARE DELETED. THE RECIPIENT INDICATOR IS SET VALUE >= 1 IF THE BENEFICIARY HAS AT LEAST ONE CLAIM FOR THIS TYPE OF SERVICE.

NOTE: IN MAX 2010, USER NOTE WAS UPDATED TO CLARIFY THAT IN MAX ALL NON-ENCOUNTER CLAIMS WITH MEDICAID PAYMENT AMOUNT LESS THAN OR EQUAL TO ZERO ARE DELETED.

SOURCE: CREATED FOR EACH OF 31 MAX TYPES OF SERVICE, USING MSIS CLAIMS FILES, AS NOTED ABOVE.

Code Code value
0 THE ELIGIBLE PERSON DID NOT RECEIVED ANY SERVICES
1 THE ELIGIBLE PERSON HAD ONLY FEE-FOR-SERVICE CLAIMS (INCLUDING CLAIMS WITH $0 PAID AMOUNTS)
2 THE ELIGIBLE PERSON HAD ONLY ENCOUNTER RECORDS (PRE-PAID PLAN)
3 THE ELIGIBLE PERSON HAD BOTH FEE-FOR-SERVICE CLAIMS AND ENCOUNTER RECORDS