Technical Instruction History
|Date||Description of Change|
|02/13/2019||Original TPI technical instruction issued for TPIs 1 - 18|
|05/09/2019||Technical instruction updated to cover TPIs 1 – 23|
|03/16/2020||Technical instruction updated and expanded to cover TPIs 1 - 32|
|11/09/2020||Technical instruction updated to reflect revisions to TPI 26 and 28 and to clarify language on thresholds|
|8/2/2021||Technical instruction language updated to clarify the expectation that MEDICAID-PAID-AMT at the line-level only needs to sum to TOT-MEDICAID-PAID-AMT at the header level when PAYMENT-LEVEL-IND is “2”, indicating that the claim payment was determined at the individual claim lines, in alignment with changes to validation rules deployed on 7/23/21|
Brief Issue Description
This document provides descriptions of T-MSIS Priority Items (TPIs) 1-32. TPIs are prioritized data quality focus areas in T-MSIS to help states improve Medicaid and CHIP data reporting accuracy and completeness.
The success of the T-MSIS hinges on the data’s reliability and usability for informing decision-making. Before states were initially approved to submit T-MSIS data in production, the state submission files underwent operational readiness testing to determine whether they were sufficiently complete and reliable. Once in production, states have access to the T-MSIS Operations Dashboard, enabling them to monitor T-MSIS file processing. States can use the T-MSIS operations dashboard to check for and address T-MSIS data submission errors. In addition, CMS provides states with technical assistance to monitor and address specific issues with data quality.
Beginning in July 2017, CMS began using the Data Quality Tool to identify and track potential data quality issues and identified 12 TPIs. States were to focus on these 12 TPIs as the highest priority of their T-MSIS data quality efforts. States have made significant progress addressing these initial TPIs. CMS expanded the TPIs in 2019 and, again, in 2020 to include additional focus areas in support of the T-MSIS data quality continuous improvement effort.
Annually, in the first quarter of the calendar year, CMS sends states a CMCS Informational Bulletin describing the T-MSIS data quality process and the annual T-MSIS data assessment requirements. In the second quarter of the year, CMS sends states baseline letters documenting the states’ level of compliance with the annual T-MSIS data assessment requirements, including the states’ progress in addressing the TPIs. In the fourth quarter, CMS provides states with formal assessments of their compliance with the T-MSIS data assessment requirements, and with the TPIs. States with data quality issues in six or more TPIs may face compliance actions. Table 1 shows the TPIs used in the T-MSIS data assessments for calendar years 2019 through 2021.
Most of the measures in the TPIs identified below identify reporting requirements and would be expected to be reported on nearly all records unless a reasonable explanation is provided. In some cases, the measure identifies data quality issues if an unreasonable percentage of records are flagged. On these records, it is expected that not all records will meet the measure criteria. However, an excessive number of records being flagged for these types of measures is indicative of a problem. For example, some claims would only be reported with one diagnosis code. If all claims are reported with only one diagnosis code, this would indicate that the other diagnosis code values are not being passed through.
Table I Annual Assessment TPIs
|2019||1 - 12|
|2020||1 - 23|
|2021||1 - 32|
Overview of T-MSIS Priority Items 01-32
TPI-01: Linking MSIS IDs from Claims and Third-Party Liability to the Eligible File
MSIS IDs are reported on the eligible (EL) file; claims files (IP, LT, OT, and RX); and third party liability (TPL) file. In order to enable analysis across the EL file, claims files, and TPL file, the format of MSIS IDs should be identical, and the identifiers reported in the claims and TPL file should be consistent with the identifiers reported in the EL file. For example, if MSIS IDs are reported with leading zeros in the EL file, then the MSIS ID on the claims files and TPL file should also have leading zeros.
It is a potential data quality issue if there are MSIS IDs in the claims files with (1) no enrollment period (ever) or (2) no enrollment on the date of service. It is also a potential data quality issue if MSIS IDs in the TPL file have no corresponding record in the EL file.
TPI-02: Duplicate Records in Non-Claims Files
States can use one of four methods when submitting non-claim files to T-MSIS: 1) true full-file refresh, 2) rolling history full-file refresh, 3) incremental timespan, or 4) changed-segment-only. Regardless of the type of submission method employed, there should be no duplicate record segments. Also known as overlapping record segments, states can identify these duplicate record segments reported as errors in the T-MSIS Operations Dashboard. T-MSIS submissions where more than a minimal number of records have a duplicate record segment are a potential data quality issue.
TPI-03: Reasonableness of Eligible Counts
There should be only one active enrollment time span segment per beneficiary for any given period of Medicaid or CHIP enrollment. The ENROLLMENT-EFF-DATE should reflect the date when the beneficiary’s enrollment began. ENROLLMENT-END-DATE should reflect the date enrollment ended or be future populated if enrollment is ongoing (e.g. 12/31/9999). ENROLLMENT-TYPE should only be coded with either “1” (Medicaid) or “2” (CHIP).
Reported T-MSIS eligible counts can be compared to the enrollment performance indicator (PI). Since the PI data only capture full-benefit enrollees, the T-MSIS enrollment used in this comparison should be limited to full-benefit enrollees using RESTRICTED-BENEFITS-CODE. After this adjustment, the number of eligible reported in T-MSIS compared to the PI reported enrollment should be comparable and reasonable. If the enrollment values differ by more than a small percent difference it indicates a potential data quality issue.
TPI-04: Reasonableness of CHIP Eligible Counts using CHIP Code
States should only use the following CHIP-CODES:
1 - Individual was Medicaid eligible, but was not included in either Medicaid-Expansion CHIP or separate Title XXI CHIP program for the month. These include blind individuals, people with disabilities, and low-income families with dependent children.
2 - Individual was included in the Medicaid-Expansion CHIP program and subject to enhanced Federal matching for the month. States with Medicaid-Expansion programs have built upon existing Medicaid programs to include low-income children whose family incomes are above Medicaid income eligibility thresholds.
3 - Individual was not Medicaid-Expansion CHIP eligible but was included in the separate Title XXI CHIP program for the month. States using separate Title XXI CHIP have used CHIP funds to create separate programs distinct from their Medicaid programs.
To assess reasonableness of CHIP eligible counts, compare the T-MSIS CHIP eligible count (CHIP-CODE = 2 + CHIP-CODE = 3) to the CHIP enrollment reported in the PI. The number of CHIP eligibles reported in T-MSIS compared to the CHIP enrollment reported in the PI should be comparable and reasonable. If the combination of Medicaid-expansion CHIP and CHIP reported in T-MSIS is not approximately equal to the CHIP enrollment reported in the PI it indicates a potential data quality issue.
TPI-05: Consistency of CHIP CODE with CHIP enrollment
Only individuals enrolled in Title XXI CHIP should be assigned a CHIP enrollment type. If an individual is enrolled only in Medicaid or only in Medicaid-expansion CHIP, they should be assigned a Medicaid enrollment type. Within T-MSIS, MSIS IDs with CHIP-CODE values of “1” and “2” for any given time period should have an ENROLLMENT-TYPE of “1” (Medicaid). CHIP-CODE “3” should have an ENROLLMENT-TYPE of “2” (CHIP) during the same time period. Reporting Medicaid-expansion CHIP eligibles (CHIP-CODE = “2”) without the Medicaid ENROLLMENT-TYPE of “1” is a potential data quality issue.
Additional measures assessing the consistency of CHIP CODE with CHIP enrollment are included in TPI-24.
TPI-06: Completeness and Robustness of Eligibility Group
The T-MSIS data dictionary defines 72 Eligibility Group values. Of these, 26 represent mandatory coverage categories and 46 reflect non-mandatory coverage categories. Eligibility Groups must be consistent with the state’s Medicaid and/or CHIP State Plan or State Plan waiver. Reporting eligible beneficiaries without a valid eligibility Group code, is a potential data quality issue.
Reported T-MSIS data should reflect enrollments in at least 21 of the 26 mandatory Eligibility Groups. In addition, (1) groups 01, 05, 06, 07, 08 and 09 should all be reported; (2) group 02 or 03 should be reported; (3) group 11 or 12 should be reported; and, (4) groups 23, 24, 25 and 26 should all be reported. When states report no enrollments in mandatory groups, it creates an open question about whether the state is correctly reporting eligibility groups or whether there are actually no eligibles for specific mandatory groups.
TPI-07: Uniqueness of Primary Eligibility Group Record
An eligibility determinant segment (ELIGIBILITY-DETERMINANTS-ELG00005) with PRIMARY-ELIGIBILITY-GROUP-IND = “1” must exist for each time span for which a person is eligible for Medicaid or CHIP. Only one eligibility segment should be assigned PRIMARY-ELIGIBILITY-GROUP-IND = “1” for any given period of coverage. Reporting MSIS IDs with more than one eligibility segment with PRIMARY-ELIGIBILITY-GROUP-IND = “1” indicates a potential data quality issue.
TPI-08: Consistency of Managed Care Plan Reporting and Cross-file Consistency
A managed care PLAN ID should be reported on the EL file on the MANAGED-CARE-PARTICIPATION-ELG00014 segment for any beneficiary who is enrolled in some type of managed care plan. The managed care PLAN ID in the EL file should match the managed care PLAN IDs reported in the other file types: managed care file (MC) and the claims files (IP, LT, OT, and RX). There should be consistent reporting of PLAN IDs and MANAGED-CARE-PLAN-TYPE across files.
Plan identifiers should be consistently reported in the EL, claims and MC files, and MANAGED-CARE-PLAN-TYPE should be reported consistently in the EL and MC files. Inconsistent and incomplete reporting are potential data quality issues. These include:
- Enrollments and/or capitation payments, with no encounters for the same PLAN IDs;
- Managed care PLAN IDs in the EL file, with no encounters or capitation payments;
- Encounters and/or capitation payments with no enrollments for the same PLAN IDs in the EL file;
- No MC file record for each PLAN ID reported in the EL and claims files; or
- The PLAN-TYPE for any given PLAN ID in the EL file is not consistent with the PLAN-TYPE for the corresponding PLAN ID in the MC file.
TPI-09: Capitation Payment Volume
Capitation claims should be reported with the PLAN ID that is also reported in the EL file for corresponding enrollment records. For managed care plans, the ratio of capitation payments to the number of enrollments should be close to 1. Potential data quality issues exist when the ratio of capitations to enrollments deviates substantially from 1.
TPI-10: Duplicate Claims
Duplicate claim header records should not be reported in T-MSIS. No two claim header records should have identical information in the following data elements:
Duplicate claim lines records should not be reported in T-MSIS. No two claim line records should have identical information in the following data elements:
It is a data quality issue if duplicate records are reported at the header or the line level.
TPI-11: Invalid Adjustment Indicator Values
There are only five meaningful valid values for ADJUSTMENT-IND and LINE-ADJUSTMENT-IND:
- 0 – Original Claim/Encounter/Payment
- 1 - Void/Reversal/Cancel of a prior submission
- 4 - Replacement/Resubmission of a previously paid/approved claim/encounter/payment
- 5 – Credit Gross Adjustment
- 6 – Debit Gross Adjustment
Values “0”, “1”, and “4” apply only to fee-for- service (FFS) claims, managed care encounters, capitation payments, and supplemental payments. Values “5” and “6” apply only to service-tracking claims. It is a data quality issue if T-MSIS claims have invalid values for ADJUSTMENT-IND or LINE-ADJUSTMENT-IND values.
TPI-12: Linking Providers from Claims to Provider Files
There are multiple ways that T-MSIS claims files can be joined to the T-MSIS provider file to get more detailed information about providers. These TPI measures assess the linking between the billing and servicing provider numbers on the claims files (billing and dispensing provider numbers for the RX file) and the submitting state provider ID or provider identifier on the provider file. The percentage of FFS claims and encounters with provider IDs that are not found in the provider file should be small. It is a potential data quality issue if an unreasonable percentage of providers on any of the claims file cannot be found in the provider file.
TPI-13: Beneficiary Demographics
States should report important demographic information on Medicaid beneficiaries on the eligible file and populate it for all or almost all beneficiaries. This includes geographic data elements and additional demographic information such as date of birth. It is a potential data quality issue if there are MSIS IDs have only missing values in any active segment for DATE-OF-BIRTH, SEX, ELIGIBLE-COUNTY-CODE, or ELIGIBLE-ZIP-CODE. Reporting unreasonable DATE-OF-BIRTH values (for example, ages greater than 120 years or less than -1 year) are also potential data quality issues.
Additional measures assessing beneficiary demographics are included in TPI-32.
TPI-14: Completeness of MSIS Identifier in the Eligible (EL) File
States must populate the MSIS Identifier on all record segments in the eligible file. It is a potential data quality issue when MSIS IDs are missing on a record. These TPI measures focus on nine segments in the EL file:
- PRIMARY-DEMOGRAPHICS-ELIGIBILITY (ELG00002)
- VARIABLE-DEMOGRAPHICS-ELIGIBILITY (ELG00003)
- ELIGIBLE-CONTACT-INFORMATION (ELG00004)
- ELIGIBILITY-DETERMINANTS (ELG00005)
- WAIVER-PARTICIPATION (ELG00012)
- MANAGED-CARE-PARTICIPATION (ELG00014)
- ETHNICITY-INFORMATION (ELG00015)
- RACE-INFORMATION (ELG00016)
- ENROLLMENT-TIME-SPAN-SEGMENT (ELG00021)
TPI-15: Consistency of Eligibility Data Elements
Several data elements provide information about a beneficiary’s eligibility for Medicaid or CHIP. States should populate these data elements for all—or almost all—beneficiaries, and the elements should be consistent. It is a potential data quality issue when the following exist:
- MSIS IDs have missing values on all record segments for RESTRICTED-BENEFITS-CODE or ENROLLMENT-TYPE-CODE,
- Medicaid-expansion CHIP eligibles are not assigned to a Medicaid-expansion CHIP eligibility group,
- CHIP eligibles are not assigned to a CHIP eligibility group,
- Medicaid eligibles are assigned to a CHIP eligibility group,
- Individuals with RESTRICTED-BENEFITS-CODE = “6” (Individual is eligible for Medicaid or Medicaid-Expansion CHIP but only entitled to restricted benefits for family planning services) with eligibility group not equal to “35” (Individuals Eligible for Family Planning Services) or “70” (Family Planning Participants [expansion group]),
- A reasonable number of MSIS IDs with RESTRICTED-BENEFITS-CODE equal “6” have claims (prescription drug or other claims files) where PROGRAM-TYPE is not equal to “02” (Family Planning),
- MSIS IDs with a valid Plan Type are missing Plan ID, or
- MSIS IDs with a non-missing Plan ID are missing Plan Type.
It is also a potential data quality issue when the expansion eligibility groups reported in T-MSIS are inconsistent with those reported in MBES enrollment reports.
Additional measures assessing the consistency eligibility data elements are included in TPI-25.
TPI-16: Completeness and Consistency of Claim Payment Data Elements
States should report FFS and encounter claims with amounts paid and billed. The paid amounts on associated claim lines should sum to the total amount reported on the claim header when claim payment is determined at the line level. It is a potential data quality issue when an unreasonable percentage the following exist:
- Records with TOT-BILLED-AMT equal to $0 or missing,
- Records with TOT-MEDICAID-PAID-AMT equal to $0 or missing,
- Records with MEDICAID-PAID-AMT equal to $0 or missing on the OT file,
- Claims for which the sum of MEDICAID-PAID-AMT from line records does not equal TOT-MEDICAID-PAID-AMT on the header when PAYMENT-LEVEL-IND equals “2” (Claim payment is determined at the individual lines),
- Claims for which TOT-MEDICAID-PAID-AMT is greater than TOT-ALLOWED-AMT on IP, LT or OT files, or
- Claims for which PAYMENT-LEVEL-IND equals “2” (Claim payment is determined at the individual lines) and MEDICAID-PAID-AMT is greater than ALLOWED-AMT on the OT file.
TPI-17: Completeness of Key Claim Service Dates
States should report service dates on all FFS and encounter claims when applicable, and they should populate beginning and ending dates of service on all capitation payment claims on the OT file. It is a potential data quality issue when the following exist:
- Claims for which PATIENT-STATUS is not equal to “30” (Still a Patient) but DISCHARGE-DATE is missing on the IP file,
- Claims for which ADMISSION-DATE or DISCHARGE-DATE is missing on the IP file,
- LT or OT claims for which BEGINNING-DATE-OF-SERVICE or ENDING-DATE-OF-SERVICE is missing on the header record,
- IP, LT, or OT claims for which BEGINNING-DATE-OF-SERVICE or ENDING-DATE-OF-SERVICE is missing on the line record,
- Claims for which PRESCRIPTION-FILL-DATE is missing, or
- Capitation payments for which BEGINNING-DATE-OF-SERVICE or ENDING-DATE-OF-SERVICE are missing on the header or line records on the OT file.
TPI-18: Completeness of Claims Classifier Data Elements
T-MSIS includes data elements that help classify the services provided or the program or benefit under which a claim was covered. These data elements are applicable to all or nearly all claims in all file types. It is a potential data quality issue when the following occur:
- Claims for which TYPE-OF-SERVICE, TYPE-OF-CLAIM, or CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT is missing or
- The percentage of claims for which PROGRAM-TYPE equals 01 (EPSDT), 02 (Family Planning), or 04 (Federally Qualified Health Centers [FQHC]) is outside of a reasonable range.
TPI-19: Reporting Dually Eligible Beneficiaries
Dually eligible beneficiaries should be reported and properly coded on the Eligible file by using the applicable DUAL-ELIGIBLE CODE. This code should be consistent with ELIGIBILITY-GROUP. It is a potential data quality issue when the following exist:
- The percentage of eligibles categorized as duals is not reasonable,
- The percentage of eligibles ages 65 and older who are categorized as duals is not reasonable,
- Eligible beneficiaries with an ELIGIBILITY-GROUP equal to 23 through 26 (QMB, QDWI, SLMB, or QI) do not have a valid DUAL-ELIGIBLE CODE,
- MSIS IDs on crossover claims are not enrolled as duals (QMB, QMB Plus, SLMB Plus, Other) on date of service,
- MSIS IDs on crossover claims are enrolled as premium-only dual groups (SLMB, QI, QDWI) on the date of service,
- Eligible beneficiaries with RESTRICTED-BENEFITS-CODE equal to “3” (Individual is eligible for Medicaid but only entitled to restricted benefits based on Medicare dual-eligibility status [e.g., QMB, SLMB, QDWI, QI]), does not have DUAL-ELIGIBLE-CODE equal to “01” (Eligible is entitled to Medicare- QMB only), “03” (Eligible is entitled to Medicare- SLMB only), “05” (Eligible is entitled to Medicare- QDWI), or “06” (Eligible is entitled to Medicare- Qualifying individuals), or
- Eligible beneficiaries with DUAL-ELIGIBLE-CODE equal to “01” (Eligible is entitled to Medicare- QMB only), “03” (Eligible is entitled to Medicare- SLMB only), “05” (Eligible is entitled to Medicare- QDWI), or “06” (Eligible is entitled to Medicare- Qualifying individuals) do not have RESTRICTED-BENEFITS-CODE equal to “3” (Individual is eligible for Medicaid but only entitled to restricted benefits based on Medicare dual-eligibility status [e.g., QMB, SLMB, QDWI, QI]).
TPI-20: Completeness of Key Claims Service Data Elements
FFS and encounter claims should include pertinent diagnostic, procedure, and drug information appropriate for the claim file and service(s). There is a potential data quality issue when an unreasonable percentage of the following exist:
- Records on the IP file contain only one diagnosis,
- Records on the IP and LT files are missing diagnosis codes,
- Records on the OT file with TYPE-OF-SERVICE equal to “002” (Outpatient hospital services), “012” (Physicians’ services), “028” (Clinic services), “041” (Preventive services), or “061” (Critical access hospital services – OT) are missing diagnosis codes,
- Records in the RX file are missing NATIONAL-DRUG-CODE, OT-RX-CLAIM-QUANTITY-ALLOWED, or DAYS-SUPPLY,
- Records in the OT file that have PLACE-OF-SERVICE populated are missing PROCEDURE-CODE,
- Records in the OT file have both TYPE-OF-BILL and PLACE-OF-SERVICE populated,
- Records in the OT file are missing TYPE-OF-BILL and PLACE-OF-SERVICE,
- Records in the OT file with non-missing TYPE-OF-BILL that have missing REVENUE-CODE,
- Records in the OT file with non-missing REVENUE-CODE that have missing TYPE-OF-BILL, or
- Records in the OT file missing PROCEDURE-CODE and REVENUE-CODE.
In addition to the conditions above, it is a potential data quality issue if the average number of diagnoses on the IP and LT files is unreasonable or if the percentage of records in the IP file with a principal procedure code is not in a reasonable range.
TPI-21: Completeness of Claim Payment Dates
Claim payment dates should be reported on all claim records. It is a potential data quality issue when records are missing MEDICAID-PAID-DATE or ADJUDICATION-DATE.
TPI-22: Completeness and Consistency of Key Provider Information on Claims
National provider identifiers (NPIs) should be reported on most claims except for nontraditional Medicaid providers that do not have an NPI (these claims are typically found in the OT file). Additional provider information, such as TYPE-OF-BILL, should be reported when applicable. It is a potential data quality issue when the following exist:
- Records are missing BILLING-PROV-NUM or BILLING-PROV-NPI-NUM,
- Records on the IP, LT, or OT files are missing SERVICING-PROV-NPI-NUM,
- Records on the RX file are missing DISPENSING-PRESCRIPTION-DRUG-PROV-NPI,
- BILLING-PROV-TAXONOMY on the IP, LT, or OT files is invalid,
- BILLING-PROV-TAXONOMY on the IP, LT, or OT files is inappropriate for the claim file type,
- TYPE-OF-BILL code is inappropriate for the claim file type on IP, LT, or OT files,
- Records on the OT claim line have accommodation revenue codes, or
- BILLING-PROV-NPI-NUM is not properly formatted.
TPI-23: Key Provider Information in the Provider File
All records in the provider file should have the facility group individual code and the identifier segment populated. The state provider identifier is used as the linking variable in T-MSIS, but the provider identifier segment should include all identifiers applicable to a state Medicaid or CHIP provider. Provider classification codes should also be reported with the applicable classification type. It is a potential data quality issue when SUBMITTING-STATE-PROV-IDs on the provider file have missing values only in active segments for the following: FACILITY-GROUP-INDIVIDUAL-CODE, PROV-IDENTIFIER, PROV-IDENTIFIER-EFF-DATE, PROV-IDENTIFIER-ISSUING-ENTITY-ID, PROV-IDENTIFIER-TYPE, PROV-CLASSIFICATION-CODE, or PROV-CLASSIFICATION-TYPE.
In addition, when states report an NPI, there should also be a taxonomy code. It is also a potential data quality issue if the SUBMITTING-STATE-PROV-IDs are associated with a PROV-IDENTIFIER-TYPE equal to “2” (NPI), but do not have any records with PROV-CLASSIFICATION-TYPE equal to “1” (Taxonomy code).
Additional measures assessing key provider information in the provider file are included in TPI-26.
TPI-24: Consistency of CHIP Code and CHIP Enrollment: Level 2
This TPI expands upon TPI-5 and checks the consistency of ENROLLMENT-TYPE with the CHIP-CODE values. Only beneficiaries enrolled in separate Title XXI CHIP should be assigned a CHIP enrollment type. Beneficiaries with CHIP-CODE values of 1 (Medicaid) or 2 (Medicaid-expansion CHIP) should have an ENROLLMENT-TYPE of 1 (Medicaid), whereas beneficiaries with a CHIP-CODE of 3 (CHIP) should have an ENROLLMENT-TYPE of 2 (separate Title XXI CHIP). TPI-5 checks the ENROLLMENT-TYPE for CHIP-CODE = 2 to address the miscoding of ENROLLMENT-TYPE for beneficiaries with Medicaid-expansion CHIP. This additional consistency check of ENROLLMENT-TYPE with the other two CHIP-CODE values will make the verification of this requirement complete. It is a potential data quality issue when eligibles have inconsistent CHIP-CODE and ENROLLMENT-TYPE values.
TPI-25: Consistency of Eligibility Data Elements: Level 2
This TPI expands upon TPI-15 and checks for consistency between RESTRICTED-BENEFIT-CODE and other data elements in accordance the Restricted Benefits Code reporting technical instruction released to states. There is a potential data quality issue when the following exist:
- Eligible beneficiaries with WAIVER-TYPE equal to “24” (1115 Family Planning demonstration) and with RESTRICTED-BENEFIT-CODE other than “6” (Individual is eligible for Medicaid or Medicaid-Expansion CHIP but only entitled to restricted benefits for family planning services),
- Eligible beneficiaries with RESTRICTED-BENEFIT-CODE equal to “C” (Individual is eligible for Separate CHIP dental coverage) that are not coded with CHIP-CODE equal to “3” (Individual was not Medicaid-Expansion CHIP eligible, but was included in separate Title XXI CHIP program for the month),
- Eligible beneficiaries found on the MFP-INFORMATION-ELG00010 segment without RESTRICTED-BENEFIT-CODE equal to “D” (Individual is eligible for Medicaid and entitled to benefits under a “Money Follows the Person” (MFP) rebalancing demonstration), or
- Eligible beneficiaries with RESTRICTED-BENEFIT-CODE equal to “D” (Individual is eligible for Medicaid and entitled to benefits under a “Money Follows the Person” (MFP) rebalancing demonstration) who are not found on the MFP-INFORMATION-ELG00010 segment.
States should also populate PRIMARY-DEMOGRAPHICS-ELIGIBILITY, VARIABLE-DEMOGRAPHICS-ELIGIBILITY, and ELIGIBILITY-DETERMINANTS record segment or segments that completely covers the time spanned on the ENROLLMENT-TIME-SPAN-SEGMENT for the same MSIS ID. It is a potential data quality issue if the MSIS IDs on the ENROLLMENT-TIME-SPAN-SEGMENT do not have a matching record on the PRIMARY-DEMOGRAPHICS-ELIGIBILITY, VARIABLE-DEMOGRAPHICS-ELIGIBILITY, and ELIGIBILITY-DETERMINANTS record segments.
TPI-26: Key Provider Information in the Provider File: Level 2
This TPI expands upon TPI-23 and will check that: (1) individual providers have only one National Provider Identifier (NPI) and (2) provider identifiers on claims link to a record in the provider file that has an active provider enrollment status. It is a potential data quality issue when the following exist:
- Individual providers with more than one PROV-IDENTIFIER-TYPE equal to “2” (NPI) or
- Claims have BILLING-PROV-NUM, SERVICING-PROV-NUM, or DISPENSING-PRESCRIPTION-DRUG-PROV-NUM with no match in the PROV-MEDICAID-ENROLLMENT-PRV00007 segment with an active provider enrollment status [PROV-MEDICAID-ENROLLMENT-STATUS-CODE equal to “01” (Active - Active Do Not Pay), “02” (Active - Active Reinstated), “03” (Active – Active), “04” (Active - Eligibility Verification), “05” (Active - Encounter Only), or “06” (Active - Financial Trans Only)] on the date of service.
TPI-27: Completeness and Consistency of Waiver Information
Waiver reporting must be consistent and complete across the eligible and claims files. 1115 and 1915(b) and 1915(c) waiver identifiers should be formatted appropriately in accordance with technical instruction that CMS released to states. In addition, this measure checks that a majority of beneficiaries enrolled in a home- and community-based services (HCBS) waiver program have at least one claim in the month with appropriate data values for PROGRAM-TYPE and HCBS-SERIVCE-CODE. It is a potential data quality issue when the following exist:
- Record segments with an invalid waiver format for 1115 waivers (WAIVER-TYPE = 01 or 22 - 30) or for 1915(b) and 1915(c) waivers (WAIVER-TYPE = 02 - 20, 32, or 33); or
- 1915(c) waiver enrollees (WAIVER-TYPE = 06 - 20 or 33) that do not have claims with the corresponding wavier ID, do not have claims with PROGRAM-TYPE = 07, or do not have claims with HCBS-SERVICE-CODE = 4; or
- Claim headers with HCBS-SERVICE-CODE = 4 that are missing WAIVER-ID
TPI-28: Supplemental and Service Tracking Claims
T-MSIS includes multiple data elements for tracking financial transactions. Financial transactions should be classified correctly and have the payment amount reported in the appropriate field. This TPI will assess the data quality of service tracking claims, and supplemental claims. Additionally, this TPI will assess if non-service tracking claims are reported with information specific to service tracking claims. It is a potential data quality issue when the following exist:
- There are service tracking claims with a non-zero Total Medicaid Amount Paid.
- There are service tracking claims that are missing a service tracking payment amount, a service tracking payment type, the MBESCBES category of service, or dates of service.
- There are non-service tracking claims with a service tracking type or service tracking payment amount that is populated.
- There are supplemental claims with a Total Medicaid Paid amount that is 0 or missing.
- There are supplemental claims with MSIS IDs that cannot be linked to the EL file.
TPI-29: Linking Headers and Lines
Each header claim should have at least one corresponding claim line, and each claim line must be associated with a header claim. It is a potential data quality issue when the following exist:
- Claim headers that have no corresponding claim lines or
- Claim lines that have no corresponding claim header.
TPI-30: Consistency on Crossover Claims
Crossover claims should have Medicare payments reported and claims with Medicare payments reported should be identified as crossovers. It is a potential data quality issue when the following exist:
- Non-crossover claims with a non-zero value for MEDICARE-PAID-AMT, TOT-MEDICARE-COINS-AMT, or TOT-MEDICARE-DEDUCTIBLE-AMT; or
- Crossover claims with a missing or $0 value for MEDICARE-PAID-AMT, TOT-MEDICARE-COINS-AMT, or TOT-MEDICARE-DEDUCTIBLE-AMT.
TPI-31: Completeness of Category of Service
The Medicaid Budget and Expenditure System/State Children's Health Insurance Program Budget and Expenditure System (MBES-CBES) category-of-service data elements should be populated for all FFS claims. It is a potential data quality issue when the following exist:
- Medicaid FFS claims with a missing value for XIX-MBESCBES-CATEGORY-OF-SERVICE; or
- CHIP FFS claims with a missing value for XXI-MBESCBES-CATEGORY-OF-SERVICE; or
- Header claims with both XIX-MBESCBES-CATEGORY-OF-SERVICE and XIX-MBESCBES-CATEGORY-OF-SERVCE populated.
TPI-32: Beneficiary Demographics: Level 2
Important demographic information on beneficiaries is reported on the eligible file and should be populated for all or almost all beneficiaries. Expanding on TPI-13, this TPI checks consistency for data elements associated with address, immigration, citizenship, and race, and will strengthen immigration status reporting. It is a potential data quality issue when the following exist:
- MSIS IDs with only missing values for CITIZENSHIP-IND or IMMIGRATION-STATUS; or
- Eligible beneficiaries with an IMMIGRATION-STATUS = 8 (US Citizen) but CITIZENSHIP-IND does not equal “1”; or
- Eligible beneficiaries with CITIZENSHIP-IND = 1 but IMMIGRATION-STATUS does not equal “8” (U.S. Citizen); or
- Eligible beneficiaries with an alien restricted benefits code status (RESTRICTED-BENEFITS-CODE = 2) but a non-immigrant immigration status (IMMIGRATION-STATUS not 1, 2, or 3); or
- MSIS IDs with an alien restricted benefits code status (RESTRICTED-BENEFITS-CODE = 2) but CITIZENSHIP-IND = 1; or
- Eligible beneficiaries without a primary address; or
- Eligible beneficiaries in which the primary home address county code, zip code, or state is out-of-state; or
- Eligible beneficiaries with AMERICAN-INDIAN-ALASKAN-NATIVE-INDICATOR = 1 but do not have RACE = 003 (American Indian or Alaskan Native).