ALL-17-007-7

Data Quality Measure

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Key Information

Measure Name	% of claim lines that have no corresponding claim header
File Type	COT
Measure ID	ALL-17-007-7
Measure Type	Claims Percentage
Content area	ALL

Validation

Validation Type	Inferential

Measure Priority

Measure Priority	N/A
Focus Area	N/A
Category	N/A

Claim Information

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

Thresholds

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

Data Elements

DD Data Element
DD Data Element Number

Annotation	Calculate the percentage of paid OT claim lines that do not link to a claim header
Specification	STEP 1: Active paid OT claims during DQ report month Define the OT claims universe at the line 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, including orphan lines 1c. Keep headers and associated lines if header is not denied; keep lines if header is missing (If header is denied also drop associated lines) 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 line duplicates Duplicates are dropped at the line level, if the following four data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and LINE-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: Orphan lines Of the claim lines that meet the criteria from STEP 1, keep claim lines that did not merge to any claim header STEP 3: Calculate percentage Divide the count of claim lines from STEP 2 by the count of claim lines from STEP 1

Annotation

Calculate the percentage of paid OT claim lines that do not link to a claim header

Specification

STEP 1: Active paid OT claims during DQ report month

Define the OT claims universe at the line 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, including orphan lines

1c. Keep headers and associated lines if header is not denied; keep lines if header is missing (If header is denied also drop associated lines)

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 line duplicates

Duplicates are dropped at the line level, if the following four data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and LINE-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: Orphan lines

Of the claim lines that meet the criteria from STEP 1, keep claim lines that did not merge to any claim header

STEP 3: Calculate percentage

Divide the count of claim lines from STEP 2 by the count of claim lines from STEP 1