An official website of the United States government

Official websites use .gov
A .gov website belongs to an official government organization in the United States.

Secure .gov websites use HTTPS
A lock () or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites.

TMSIS Dataguide Medicaid.gov
Version 3.38.0

ALL-21-008-8

Data Quality Measure
Last updated

Key Information

Measure Name % of DISPENSING-PRESCRIPTION-DRUG-PROV-NUM on claim headers that do not have a match in PRV00007 with active provider enrollment status (PROV-MEDICAID-ENROLLMENT-STATUS-CODE in (1, 2, 3, 4, 5, 6) on Prescription Fill Date
File Type Multiple Files
Measure ID ALL-21-008-8
Measure Type Claims Percentage
Content area ALL MULTI PRO

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,Enc or CHIP,FFS or CHIP,Enc
Adjustment Type All Adjustment Types
Crossover Type All Indicators

Thresholds

Minimum 0
Maximum 0.05
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 DISPENSING-PRESCRIPTION-DRUG-PROV-NUM • SUBMITTING-STATE-PROV-ID • PROV-MEDICAID-ENROLLMENT-STATUS-CODE • PRESCRIPTION-FILL-DATE • PROV-MEDICAID-EFF-DATE • PROV-MEDICAID-END-DATE
DD Data Element Number CRX156 • PRV097 • PRV100 • CRX085 • PRV098 • PRV099

Annotation Calculate the percentage of unique dispensing prescription drug provider numbers on Medicaid and S-CHIP FFS and Encounter: original and adjustment, paid RX claims that do not have an active record indicating they are a Medicaid-enrolled provider on a claim prescription fill date
Specification STEP 1: Active non-duplicate paid RX claims during report month

Define the RX claims universe at the header level that satisfy the following criteria:

1. Reporting Period from the filename = DQ report month

2. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing

3. CLAIM-DENIED-INDICATOR is not equal to "0" or is missing

4. TYPE-OF-CLAIM is not equal to "Z" or is missing

5. CLAIM-STATUS is not equal to ("26","026","87","087","542","585", "654") or is missing

6. No 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.



STEP 2: Medicaid and S-CHIP FFS and Encounter: Original and Adjustment, Paid Claims

Of the claims that meet the criteria from STEP 1, further restrict them by the following criteria:

1. TYPE-OF-CLAIM = "1" or "3" or "A" or "C"



STEP 3: Unique dispensing provider numbers on the claims

From the claims that meet the criteria from STEP 2, create a list of unique DISPENSING-PRESCRIPTION-DRUG-PROV-NUM values where:

1. DISPENSING-PRESCRIPTION-DRUG-PROV-NUM is not missing



STEP 4: Providers without enrollment on the prescription fill date

Of the unique provider identifiers from STEP 3, refine the list using PROV-MEDICAID-ENROLLMENT-PRV00007 by keeping providers that do not meet all of the following criteria for all claims:

1. DISPENSING-PRESCRIPTION-DRUG-PROV-NUM found in SUBMITTING-STATE-PROV-ID

2. PROV-MEDICAID-ENROLLMENT-STATUS-CODE = ("1" or "01") or ("2" or "02") or ("3" or "03") or ("4" or "04") or ("5" or "05") or ("6" or "06")

3. PRESCRIPTION-FILL-DATE from the claim is greater than or equal to PROV-MEDICAID-EFF-DATE

4a. PRESCRIPTION-FILL-DATE from the claim is less than or equal to PROV-MEDICAID-END-DATE

OR

4b. PROV-MEDICAID-END-DATE is missing



STEP 5: Calculate percentage

Divide the count of unique providers from STEP 4 by the count from STEP 3