MCR-63-003-3

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TMSIS Dataguide

Medicaid.gov

Version 3.38.0

MCR-63-003-3

Data Quality Measure

Last updated

Key Information

Measure Name	% of non-crossover claim headers where MEDICARE-PAID-AMT, TOT-MEDICARE-COINS-AMT, or TOT-MEDICARE-DEDUCTIBLE-AMT is non-zero
File Type	COT
Measure ID	MCR-63-003-3
Measure Type	Claims Percentage
Content area	MCR

Validation

Validation Type	Inferential

Measure Priority

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

Claim Information

Claim Type	Medicaid,Enc or CHIP,Enc
Adjustment Type	All Adjustment Types
Crossover Type	Non-Crossover

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	MEDICARE-PAID-AMT • TOT-MEDICARE-COINS-AMT • TOT-MEDICARE-DEDUCTIBLE-AMT
DD Data Element Number	COT182 • COT053 • COT052

Annotation	N/A
Specification	N/A

Published Date	Data Guide Version	DQM	Action	Field	Before	After
02/02/2024	3.18.0	MCR-63-003-3	UPDATE	Focus area	Managed care	N/A
04/21/2023	3.6.0	MCR-63-003-3	UPDATE	Priority	High	N/A
04/21/2023	3.6.0	MCR-63-003-3	UPDATE	Category	Expenditures	N/A
04/21/2023	3.6.0	MCR-63-003-3	UPDATE	For ta comprehensive	TA- Inferential	No
04/21/2023	3.6.0	MCR-63-003-3	UPDATE	For ta inferential	Yes	No
04/21/2023	3.6.0	MCR-63-003-3	UPDATE	Ta min	0
04/21/2023	3.6.0	MCR-63-003-3	UPDATE	Ta max	0.001
04/21/2023	3.6.0	MCR-63-003-3	UPDATE	Annotation	Calculate the percentage of Medicaid and S-CHIP encounter: original and adjustment, non-crossover, paid OT claims where Medicare paid amount, total Medicare coinsurance amount, or total Medicare deductible amount is non-zero	N/A
04/21/2023	3.6.0	MCR-63-003-3	UPDATE	Specification	STEP 1: Active non-duplicate OT records during DQ report monthDefine the OT records universe at the header level by importing both headers and lines that satisfy the following criteria:For Headers:1. Reporting Period for the filename = DQ report month2. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing3. CLAIM-DENIED-INDICATOR is not equal to "0" or is missing4. TYPE-OF-CLAIM is not equal to "Z" or is missing5. CLAIM-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing6. 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 month2. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing3. 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: Medicaid and S-CHIP Encounter: Original and Adjustment, Non-Crossover, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "3" or "C"2. CROSSOVER-INDICATOR = "0" or is missingSTEP 3: Non-zero Medicare AmountsOf the claims that meet the criteria from STEP 2, further restrict them by the following criteria:1a. MEDICARE-PAID-AMT is non-zero on any lineOR1b. TOT-MEDICARE-COINS-AMT is non-zeroOR 1c. TOT-MEDICARE-DEDUCTIBLE-AMT is non-zeroSTEP 4: Calculate percentageDivide the count of claim headers from STEP 3 by the count of claim headers in STEP 2	N/A