Key Information

Measure Name	% of claim lines on claims where Payment Level Indicator = 2 with Medicaid Paid Amount = $0 or missing
File Type	COT
Measure ID	EXP-13-004_1-7
Measure Type	Claims Percentage
Content area	EXP

Validation

Validation Type	Longitudinal and Inferential

Measure Priority

Measure Priority	High
Focus Area	N/A
Category	Expenditures

Claim Information

Claim Type	CHIP,FFS
Adjustment Type	Original
Crossover Type	Non-Crossover

Thresholds

Minimum	0
Maximum	0.1
TA Minimun	0
TA Maximum	0.1
Longitudinal Threshold	0.15
For TA (for including in compliance training)	TA- Inferential
For TA (Longitudinal)	No

Data Elements

DD Data Element	MEDICAID-PAID-AMT
DD Data Element Number	COT178

Annotation

Calculate the percentage of S-CHIP FFS: original, non-crossover, paid OT claims billed at the line level where Medicaid paid amount is equal to $0 or missing

Specification

STEP 1: Active non-duplicate paid OT claims during report month Define the OT claims universe at the line level by importing both headers and lines that satisfy the following criteria: For Headers: 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. For Lines: 1. Reporting Period from the filename = DQ report month 2. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing 3. No Line Duplicates: Duplicates are dropped at the line level if the following data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, LINE-NUM-ORIG, LINE-NUM-ADJ, and LINE-ADJSTMT-IND. 4. Lines merge to a header using ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND=LINE-ADJSTMT-IND. STEP 2: S-CHIP FFS: Original, Non-Crossover, Paid Claims Of the claims that meet the criteria from STEP 1, further restrict them by the following criteria: 1. TYPE-OF-CLAIM = "A" 2. ADJUSTMENT-IND = "0" 3. CROSSOVER-INDICATOR = "0" or is missing STEP 3: Payment at the line level Of the claims that meet the criteria from STEP 2, count records where: 1. PAYMENT-LEVEL-IND = "2" STEP 4: Medicaid paid $0 or missing Of the claims that meet the criteria from STEP 3, restrict to claims that meet the following criteria: 1. MEDICAID-PAID-AMT = "0" or is missing STEP 5: Calculate percentage Divide the number of claims from STEP 4 by the number of claims from STEP 3.