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Measure Name | % of claim headers that have no corresponding claim lines |
---|---|
File Type | COT |
Measure ID | ALL-17-003-3 |
Measure Type | Claims Percentage |
Content area | ALL |
Validation Type | Inferential |
---|
Measure Priority | N/A |
---|---|
Focus Area | N/A |
Category | N/A |
Claim Type | Medicaid,FFS or Medicaid,Cap or Medicaid,Enc or Medicaid,Serv or Medicaid,Supp or CHIP,FFS or CHIP,Cap or CHIP,Enc or CHIP,Serv or CHIP,Supp |
---|---|
Adjustment Type | All Adjustment Types |
Crossover Type | All Indicators |
Minimum | 0 |
---|---|
Maximum | 0.001 |
TA Minimun | |
TA Maximum | |
Longitudinal Threshold | N/A |
For TA
(for including in compliance training) |
No |
For TA
(Longitudinal) |
No |
DD Data Element | |
---|---|
DD Data Element Number |
Annotation | Calculate the percentage of paid OT claim headers that do not have corresponding claim lines |
---|---|
Specification |
STEP 1: Active paid OT claims during DQ report month Define the OT claims universe at the header level by importing both headers and lines that satisfy the following criteria: 1a. Limit to Report Month Reporting Period from the filename = DQ report month 1b. Join Headers and Lines Merge headers and lines using: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND=LINE-ADJSTMT-IND, and keep all claims, even if there is no match 1c. Keep headers and associated lines if header is not denied 1. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing 2. CLAIM-DENIED-INDICATOR is not equal to "0" or is missing 3. TYPE-OF-CLAIM is not equal to "Z" or is missing 4. CLAIM-STATUS is not equal to ("26","026","87","087","542","585", "654") or is missing 1d. Drop Header Duplicates Duplicates are dropped at the header level, if the following four data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND. 1e. Keep line if line is not denied 1. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing STEP 2: Childless headers Of the claim headers that meet the criteria from STEP 1, keep claim headers that did not merge to any claim line STEP 3: Calculate percentage Divide the count of claim headers from STEP 2 by the count of claim headers from STEP 1 |