ALL-5-008-8

Data Quality Measure

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Key Information

Measure Name	% of duplicate claim lines
File Type	CRX
Measure ID	ALL-5-008-8
Measure Type	Duplicate 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 unique RX claim line records that appear more than once
Specification	STEP 1: Active paid RX claims during DQ report month Define the RX 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. 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: Total Count Of the claims that meet the criteria from STEP 1, count the number of unique line records. A unique line record is defined by distinct combinations of the following data elements: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, LINE-NUM-ORIG, LINE-NUM-ADJ, and LINE-ADJUSTMENT-IND. STEP 3: Count duplicates From the records in STEP 1, count unique line records that appear more than once STEP 4: Percentage Divide the count of unique line records from STEP 3 by the count in STEP 2

Annotation

Calculate the percentage of unique RX claim line records that appear more than once

Specification

STEP 1: Active paid RX claims during DQ report month

Define the RX 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. 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: Total Count

Of the claims that meet the criteria from STEP 1, count the number of unique line records. A unique line record is defined by distinct combinations of the following data elements: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, LINE-NUM-ORIG, LINE-NUM-ADJ, and LINE-ADJUSTMENT-IND.

STEP 3: Count duplicates

From the records in STEP 1, count unique line records that appear more than once

STEP 4: Percentage

Divide the count of unique line records from STEP 3 by the count in STEP 2