FFS-49-008-8

Data Quality Measure

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Key Information

Measure Name	% of claim headers that have Total Medicaid Paid Amount greater than a non-zero Total Allowed Amount
File Type	CRX
Measure ID	FFS-49-008-8
Measure Type	Claims Percentage
Content area	FFS

Validation

Validation Type	Inferential

Measure Priority

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

Claim Information

Claim Type	Medicaid,FFS or CHIP,FFS
Adjustment Type	Original
Crossover Type	All Indicators

Thresholds

Minimum	N/A
Maximum	N/A
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	TOT-MEDICAID-PAID-AMT • TOT-ALLOWED-AMT
DD Data Element Number	CRX041 • CRX040

Annotation	Calculate the percentage of Medicaid and S-CHIP FFS: original, paid RX claims where the total Medicaid paid amount is greater than the total allowed amount
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: Original, 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 "A" 2. ADJUSTMENT-IND = "0" STEP 3: Non-missing total Medicaid paid and allowed amounts Of the records from STEP 2, further refine the population with the following criteria: 1. TOT-MEDICAID-PAID-AMT is not missing 2. TOT-ALLOWED-AMT is not missing 3. TOT-ALLOWED-AMT is not equal to zero STEP 4: Total Medicaid paid is greater than total allowed Of the records from STEP 3, further refine the population with the following criteria: 1. TOT-MEDICAID-PAID-AMT > TOT-ALLOWED-AMT STEP 5: Percentage Divide the count of claims from STEP 4 by the count of claims from STEP 3

Annotation

Calculate the percentage of Medicaid and S-CHIP FFS: original, paid RX claims where the total Medicaid paid amount is greater than the total allowed amount

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: Original, 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 "A"

2. ADJUSTMENT-IND = "0"

STEP 3: Non-missing total Medicaid paid and allowed amounts

Of the records from STEP 2, further refine the population with the following criteria:

1. TOT-MEDICAID-PAID-AMT is not missing

2. TOT-ALLOWED-AMT is not missing

3. TOT-ALLOWED-AMT is not equal to zero

STEP 4: Total Medicaid paid is greater than total allowed

Of the records from STEP 3, further refine the population with the following criteria:

1. TOT-MEDICAID-PAID-AMT > TOT-ALLOWED-AMT

STEP 5: Percentage

Divide the count of claims from STEP 4 by the count of claims from STEP 3