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PRA Disclosure Statement: The Transformed Medicaid Statistical Information System (T-MSIS) is used to assist the Centers for Medicare & Medicaid Services (CMS) with monitoring and oversight of Medicaid and CHIP programs, to enable evaluation of demonstrations under section 1115 of the Social Security Act and to calculate quality measures and other metrics, including those reported through the new Medicaid and CHIP Scoreboard. Section 4735 of the Balanced Budget Act of 1997 included a statutory requirement for states to submit claims data, enrollee encounter data, and supporting information. Section 6504 of the Affordable Care Act strengthened this provision by requiring states to include data elements the Secretary determines necessary for program integrity, program oversight, and administration. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0345 (Expires: 03/31/2026). The time required to complete this information collection is estimated to average 10 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
T-MSIS makes available a Data Dictionary to support access to T-MSIS data requirements quickly and easily through an online Data Guide. This version on Medicaid.gov allows you to access the Data Dictionary which is sortable, filterable, searchable, and downloadable.
The Data Guide is the online version of the T-MSIS data dictionary. It brings you the specifications for the T-MSIS files and their components of the File Segments and Data Elements, as well as Validation Rules, Data Quality Measures and Data Dictionary Appendices. The five tiles here bring you to the different features of the Data Guide.
The File Segment Layouts tile brings you to a list of the 8 T-MSIS file types, their layouts, and their requirements. The Validation Rules tile will bring you to a list of all active validation rules and their details such as the validation logic. The Data Elements tile will be a subset of the information that you can see in the File Segment Layouts tile but focus on the full list of Data Elements available in T-MSIS.
You can use the Glossary icon from the Landing Page to download a file with a full glossary of all T-MSIS terms. You can also click on the View Changelog link if you wish to see the changelog in its entirety. To see filtered changelog items, you can choose the View Changelog link from the individual Data Guide tiles. Most tables can be sorted or searched or filtered. And anything in blue will be an active link that will bring you to more another page with more details.
The Data Quality Measures provide specifications for the inferential measures used to access data quality. The Data Dictionary Appendices are a consolidated resource of data dictionary material.
These tiles enable users to search and sort the content for quick access to the documentation. Content, including valid values and validation rules, is updated with each release so that the information is never out of date.
All 8 T-MSIS file types can be seen from this tile and will give you all the information that makes up that file, including the file segments and data elements descriptions and requirements. Clicking on the “View Changelog” link will give you the changelog for all the file segments. Clicking the download icon will download a file shows descriptions of the file segments layouts and their relationships. If you are looking for a list of all the data elements included in each file segment, you can get this file from the Data Elements tab. Drilling down into any of the file types will give you all the segments that comprise the file type. You can also see descriptive details for the file type from the “Reference” tab. Clicking into any of the file segments will give you the full list of data elements that make up that segment. Again, you can see the description for the file segment under the “Reference” tab. Drilling down into any of the data elements will give you all the details for that data element, specific to that segment.
This tile gives you the full list of T-MSIS Data Elements. The type ahead search function will give results back from not only the Data Element name, but for any of the information listed in the columns. Clicking on the “View Changelog” link will give you the changelog for all the data elements. To see the entirety of the changelog for all data elements, be sure you are on the Data Elements home page. Clicking the download icon will download the list of every data elements in each file segment, including their attributes and start and stop positions for FLF files. Each column can also be sorted by clicking on its title. You will see two data element numbers. One is the same number that has been used for the past several years. The second is a new data element number which is meant to be more intuitive and informative. You will see it includes the segment number in the data element number. Clicking on the data element number will bring you to a data element’s landing page. This page is specific to the data element of that file segment. You will see the details and requirements for that data element on the “Overview” tab. The “Valid Values” tab will show a full list of valid values for that data element. A few data elements will not include the full list of valid values but instead link you to the source material. The search function will give results back from any of the information listed in the columns shown. You will often see only one of the following populated: valid value name or valid value description. This is to be expected. Each column can also be sorted by clicking on its title. Data elements that do not have any associated valid values will show as message as such. The “Related Rules” tab will show any validation rules in which the data element (specific to the data element number) is critical in its evaluation. The “Other Instances” tab will list all other segments which have the same data element. Data elements that are not present in any other segment will show as message as such. Again, anything in blue will be an active link, such as the file segment listed in the header.
The Data Dictionary Appendices will include a list of menu tiles with the option for scrolling on the left-hand side. These are the full list of appendices with their description heading. Appendices ranging from Taxonomy values, codes for Medicaid/CHIP programs, eligibility and benefit types, category of service line definitions, claim adjustment, reporting financial transactions and qualifier fields with their associated value fields. Based on the selection of the left-hand side menu, you can view fully descriptive tables on the right-hand side and where applicable links to the relevant CMS.gov page.
This tile gives you the current list of all the active rules. The type ahead search function will give results back from not only the RULE ID, but for any of the information listed in the columns. Clicking on the “View Changelog” link will give you the changelog for all the validation rules. To see the entirety of the changelog for all validation rules, be sure you are on the Validation Rules home page. Clicking the download icon will download a file which includes each validation rule and their attributes. Each column can also be sorted by clicking on its title. Clicking into any rule you will see the full description of the rule. Anything in blue will be an active link.
The Data Quality Measures combines the measure specifications with the data quality measure details and thresholds, allowing you to query and browse information about all the T-MSIS data quality measures. The Measure information on the Measures Directory Landing page is displayed via Measure ID, Measure Name, Priority, File Type, Type of Claim, Adjustment Type, Crossover Indicator, Category and Focus Area.
You can drill down to the key information related to a Measure by selecting the Measure ID. This view will also display the Annotation and Specifications related to a Measure ID. For any Measure with related Rules, user can navigate to view the RULEs details by selecting the displayed RULEs (displayed under Specification field). You can navigate to the Data Element detail page by clicking on the DD Data Element number.
Download option is available on the title bar of the Measures Directory pages which will allow you to export the Measures related documents: Threshold and Measure Specification file.
The Data Guide document downloads are live and current and will produce documents identical to the information you see on the screen.
The changelog download is also live and will provide information identical to the information you see on the screen. If you wish to see the changelog in its entirety, be sure you are on the landing page of the Data Guide to see the changelog from all the different Data Guide tiles.
The Data Guide version number X.Y.Z. will reflect the MAJOR.MINOR.PATCH and will increment as follows.
Patch version Z (x.y.Z) will be incremented if any documentation correction or changes are introduced. For example, a correction or update in data element (DE) coding requirements, DE definition, or any other documentation, including appendix document, Validation Rule, and DQ Measure Specification.
Minor version Y (x.Y.z) will be incremented if a minor feature/functionality is introduced. It MAY include patch level changes. Patch version will be reset to 0 when the minor version is incremented. For example, when new Validation Rules or DQ Measures are introduced, existing Rules or Measures logic is modified, and updates are made to T-MSIS National Valid Values.
Major version X (X.y.z) will be incremented if any major functionality is introduced. It MAY also include minor and patch level changes. Patch and minor versions will be reset to 0 when the major version is incremented. This is applicable only when T-MSIS Record Layout Changes are implemented.
Published Date | Data Guide Version | Document | Action | Field | Before | After |
---|---|---|---|---|---|---|
06/19/2024 | 3.27.0 | RULE-7421 | ADD | N/A | Created | |
06/19/2024 | 3.27.0 | RULE-7420 | ADD | N/A | Created | |
06/19/2024 | 3.27.0 | RULE-7419 | ADD | N/A | Created | |
06/19/2024 | 3.27.0 | RULE-7912 | ADD | N/A | Created | |
06/19/2024 | 3.27.0 | RULE-7908 | ADD | N/A | Created | |
06/19/2024 | 3.27.0 | RULE-7824 | ADD | N/A | Created | |
06/19/2024 | 3.27.0 | RULE-7759 | ADD | N/A | Created | |
06/19/2024 | 3.27.0 | RULE-7827 | ADD | N/A | Created | |
06/19/2024 | 3.27.0 | RULE-7763 | ADD | N/A | Created | |
06/19/2024 | 3.27.0 | RULE-7911 | ADD | N/A | Created | |
06/19/2024 | 3.27.0 | RULE-7907 | ADD | N/A | Created | |
06/19/2024 | 3.27.0 | RULE-7919 | ADD | N/A | Created | |
06/19/2024 | 3.27.0 | RULE-7914 | ADD | N/A | Created | |
06/19/2024 | 3.27.0 | RULE-7823 | ADD | N/A | Created | |
06/19/2024 | 3.27.0 | RULE-7758 | ADD | N/A | Created | |
06/19/2024 | 3.27.0 | RULE-7910 | ADD | N/A | Created | |
06/19/2024 | 3.27.0 | RULE-7906 | ADD | N/A | Created | |
06/19/2024 | 3.27.0 | RULE-7918 | ADD | N/A | Created | |
06/19/2024 | 3.27.0 | RULE-7913 | ADD | N/A | Created | |
06/19/2024 | 3.27.0 | RULE-7822 | ADD | N/A | Created | |
06/19/2024 | 3.27.0 | RULE-7757 | ADD | N/A | Created | |
06/19/2024 | 3.27.0 | RULE-7820 | ADD | N/A | Created | |
06/19/2024 | 3.27.0 | RULE-7762 | ADD | N/A | Created | |
06/19/2024 | 3.27.0 | RULE-7909 | ADD | N/A | Created | |
06/19/2024 | 3.27.0 | RULE-7905 | ADD | N/A | Created | |
06/19/2024 | 3.27.0 | RULE-7917 | ADD | N/A | Created | |
06/19/2024 | 3.27.0 | RULE-7916 | ADD | N/A | Created | |
06/19/2024 | 3.27.0 | RULE-7821 | ADD | N/A | Created | |
06/19/2024 | 3.27.0 | RULE-7756 | ADD | N/A | Created | |
06/19/2024 | 3.27.0 | RULE-7818 | ADD | N/A | Created | |
06/19/2024 | 3.27.0 | RULE-7760 | ADD | N/A | Created | |
06/19/2024 | 3.27.0 | EL-6-041-41 | ADD | N/A | Created | |
06/19/2024 | 3.27.0 | EL-3-034-43 | ADD | N/A | Created | |
06/19/2024 | 3.27.0 | EL-3-033-42 | ADD | N/A | Created | |
06/19/2024 | 3.27.0 | RULE-7381 | UPDATE | Measure name | % of distinct MSIS IDs with only missing values for IMMIGRATION-STATUS | % of record segments with missing Immigration Status |
03/27/2024 | 3.22.0 | RULE-7381 | ADD | N/A | Created | |
06/19/2024 | 3.27.0 | RULE-7380 | UPDATE | Measure name | % of distinct MSIS IDs with only missing values for CITIZENSHIP-IND | % of record segments with missing Citizenship Indicator |
03/27/2024 | 3.22.0 | RULE-7380 | ADD | N/A | Created | |
06/19/2024 | 3.27.0 | RULE-7528 | UPDATE | Measure name | % of MSIS IDs with an IMMIGRATION-STATUS = 8 (U.S. Citizen) but CITIZENSHIP-IND does not equal 1 | % of record segments with an IMMIGRATION-STATUS = 8 (Not applicable) but CITIZENSHIP-IND does not equal 1 or 2 (U.S. Citizen or U.S. National) |
03/27/2024 | 3.22.0 | RULE-7528 | ADD | N/A | Created | |
06/19/2024 | 3.27.0 | RULE-7529 | UPDATE | Measure name | % of MSIS IDs with an alien restricted benefits code status (RESTRICTED-BENEFITS-CODE = 2) but a non-qualified alien immigration status (IMMIGRATION-STATUS not 1, 2, or 3) | % of record segments with an alien restricted benefits code status (RESTRICTED-BENEFITS-CODE = 2) but a non-qualified alien immigration status (IMMIGRATION-STATUS not 1, 2, or 3) |
03/27/2024 | 3.22.0 | RULE-7529 | ADD | N/A | Created | |
06/19/2024 | 3.27.0 | RULE-2157 | UPDATE | Measure name | % of MSIS IDs with an alien restricted benefits code status (RESTRICTED-BENEFITS-CODE = 2) but CITIZENSHIP-IND = 1 | % of record segments with an alien restricted benefits code status (RESTRICTED-BENEFITS-CODE = 2) but CITIZENSHIP-IND = 1 or 2 (U.S. Citizen or U.S. National) |
06/19/2024 | 3.27.0 | RULE-2051 | UPDATE | Measure name | % of MSIS IDs with CITIZENSHIP-IND = 1 but IMMIGRATION-STATUS does not equal 8 (U.S. Citizen) | % of record segments with CITIZENSHIP-IND = 1 or 2 (U.S. Citizen or U.S. National) but IMMIGRATION-STATUS does not equal 8 (Not applicable) |
03/27/2024 | 3.22.0 | RULE-2051 | ADD | N/A | Created | |
06/19/2024 | 3.27.0 | RULE-7980 | UPDATE | Measure name | % of eligibles where zip code does not align with address state and is not missing | % of record segments where zip code does not align with address state and is not missing |
03/27/2024 | 3.22.0 | RULE-7980 | ADD | N/A | Created | |
06/19/2024 | 3.27.0 | RULE-7532 | UPDATE | Measure name | % of eligibles where county code does not align with address state and is not missing | % of record segments where county code does not align with address state and is not missing |
03/27/2024 | 3.22.0 | RULE-7532 | ADD | N/A | Created | |
03/27/2024 | 3.22.0 | RULE-7364 | ADD | N/A | Created | |
03/27/2024 | 3.22.0 | RULE-7363 | ADD | N/A | Created | |
03/27/2024 | 3.22.0 | RULE-7362 | ADD | N/A | Created | |
03/27/2024 | 3.22.0 | RULE-7361 | ADD | N/A | Created | |
03/27/2024 | 3.22.0 | RULE-7360 | ADD | N/A | Created | |
03/27/2024 | 3.22.0 | RULE-7359 | ADD | N/A | Created | |
03/27/2024 | 3.22.0 | RULE-7358 | ADD | N/A | Created | |
03/27/2024 | 3.22.0 | EL-3-032-41 | ADD | N/A | Created | |
03/27/2024 | 3.22.0 | EL-3-031-40 | ADD | N/A | Created | |
03/27/2024 | 3.22.0 | EL-3-030-39 | ADD | N/A | Created | |
03/27/2024 | 3.22.0 | EL-6-047-47 | ADD | N/A | Created | |
03/27/2024 | 3.22.0 | EL-6-046-46 | ADD | N/A | Created | |
03/27/2024 | 3.22.0 | EL-6-045-45 | ADD | N/A | Created | |
03/27/2024 | 3.22.0 | EL-6-044-44 | ADD | N/A | Created | |
03/27/2024 | 3.22.0 | EL-6-043-43 | ADD | N/A | Created | |
03/27/2024 | 3.22.0 | EL-6-042-42 | ADD | N/A | Created | |
03/27/2024 | 3.22.0 | EL-6-040-40 | ADD | N/A | Created | |
03/27/2024 | 3.22.0 | EL-6-039-39 | ADD | N/A | Created | |
03/27/2024 | 3.22.0 | EL-6-038-38 | ADD | N/A | Created | |
03/27/2024 | 3.22.0 | ALL-16-023-23 | ADD | N/A | Created | |
03/27/2024 | 3.22.0 | ALL-16-022-22 | ADD | N/A | Created | |
03/27/2024 | 3.22.0 | ALL-16-021-21 | ADD | N/A | Created | |
03/27/2024 | 3.22.0 | ALL-16-020-20 | ADD | N/A | Created | |
03/27/2024 | 3.22.0 | ALL-16-019-19 | ADD | N/A | Created | |
03/27/2024 | 3.22.0 | ALL-16-018-18 | ADD | N/A | Created | |
03/27/2024 | 3.22.0 | ALL-16-017-17 | ADD | N/A | Created | |
03/27/2024 | 3.22.0 | ALL-16-016-16 | ADD | N/A | Created | |
03/27/2024 | 3.22.0 | MIS-6-024_43 | ADD | N/A | Created | |
03/27/2024 | 3.22.0 | MIS-6-024_42 | ADD | N/A | Created | |
09/12/2024 | 3.29.0 | TPL.006.082 | UPDATE | Coding requirement | 1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011)2. Situational | 1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011)2. Situational3. Value must be in ZIP Code List (VVL) |
09/12/2024 | 3.29.0 | PRV.003.052 | UPDATE | Coding requirement | 1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011)2. Mandatory | 1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011)2. Mandatory3. Value must be in ZIP Code List (VVL) |
09/12/2024 | 3.29.0 | MCR.003.047 | UPDATE | Coding requirement | 1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011)2. Mandatory | 1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011)3. Value must be in ZIP Code List (VVL)2. Mandatory |
09/12/2024 | 3.29.0 | ELG.004.071 | UPDATE | Coding requirement | 1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011)2. Mandatory | 1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011)2. Mandatory3. Value must be in ZIP Code List (VVL) |
09/12/2024 | 3.29.0 | COT.003.208 | UPDATE | Coding requirement | 1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011)2. Conditional | 3. Value must be in ZIP Code List (VVL)1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011)2. Conditional |
09/12/2024 | 3.29.0 | COT.003.203 | UPDATE | Coding requirement | 1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011)2. Conditional | 1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011)3. Value must be in ZIP Code List (VVL)2. Conditional |
06/19/2024 | 3.27.0 | Data Quality Measures | UPDATE | Version text | 3.11.0 | 3.12.0 |
09/12/2024 | 3.29.0 | CIP.002.291 | UPDATE | Coding requirement | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated End of Time Period value4. Value must be greater than or equal to associated Beginning Date of Service value5. When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated Adjudication Date value6. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated7. Value must be equal to or greater than associated Date of Birth (ELG.002.024) value8. Mandatory | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When Type of Claim is not in [2,4,B,D,V] value must be less than or equal to associated End of Time Period value4. Value must be greater than or equal to associated Beginning Date of Service value5. When Type of Claim is not in [2,4,B,D,V] value must be less than or equal to associated Adjudication Date value6. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated7. Value must be equal to or greater than associated Date of Birth (ELG.002.024) value8. Mandatory |
09/12/2024 | 3.29.0 | CIP.002.290 | UPDATE | Coding requirement | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated End of Time Period value4. Value must be less than or equal to associated Ending Date of Service value5. When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated Adjudication Date value6. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated7. Value must be less than or equal to at least one of the eligible's Enrollment End Date (ELG.021.254) values8. Mandatory | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When Type of Claim is not in [2,4,B,D,V] value must be less than or equal to associated End of Time Period value4. Value must be less than or equal to associated Ending Date of Service value5. When Type of Claim is not in [2,4,B,D,V] value must be less than or equal to associated Adjudication Date value6. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated7. Value must be less than or equal to at least one of the eligible's Enrollment End Date (ELG.021.254) values8. Mandatory |
02/02/2024 | 3.18.0 | RULE-7753 | ADD | N/A | Created | |
02/02/2024 | 3.18.0 | RULE-7754 | ADD | N/A | Created | |
02/02/2024 | 3.18.0 | RULE-7755 | ADD | N/A | Created | |
02/02/2024 | 3.18.0 | RULE-7752 | ADD | N/A | Created | |
02/02/2024 | 3.18.0 | RULE-7902 | ADD | N/A | Created | |
02/02/2024 | 3.18.0 | RULE-7903 | ADD | N/A | Created | |
02/02/2024 | 3.18.0 | RULE-7904 | ADD | N/A | Created | |
02/02/2024 | 3.18.0 | RULE-7901 | ADD | N/A | Created | |
02/02/2024 | 3.18.0 | RULE-7320 | ADD | N/A | Created | |
02/02/2024 | 3.18.0 | RULE-7316 | ADD | N/A | Created | |
02/02/2024 | 3.18.0 | RULE-7319 | ADD | N/A | Created | |
02/02/2024 | 3.18.0 | RULE-7315 | ADD | N/A | Created | |
02/02/2024 | 3.18.0 | RULE-7318 | ADD | N/A | Created | |
02/02/2024 | 3.18.0 | RULE-7314 | ADD | N/A | Created | |
02/02/2024 | 3.18.0 | RULE-7317 | ADD | N/A | Created | |
02/02/2024 | 3.18.0 | RULE-7313 | ADD | N/A | Created | |
03/27/2024 | 3.22.0 | RULE-7751 | UPDATE | Measure name | % of claim headers with missing Prescription Quantity Actual | % of claim lines with missing Prescription Quantity Actual |
02/02/2024 | 3.18.0 | RULE-7751 | ADD | N/A | Created | |
03/27/2024 | 3.22.0 | RULE-7817 | UPDATE | Measure name | % of claim headers with missing Prescription Quantity Actual | % of claim lines with missing Prescription Quantity Actual |
02/02/2024 | 3.18.0 | RULE-7817 | ADD | N/A | Created | |
03/27/2024 | 3.22.0 | RULE-7750 | UPDATE | Measure name | % of claim headers with missing Days Supply | % of claim lines with missing Days Supply |
02/02/2024 | 3.18.0 | RULE-7750 | ADD | N/A | Created | |
03/27/2024 | 3.22.0 | RULE-7816 | UPDATE | Measure name | % of claim headers with missing Days Supply | % of claim lines with missing Days Supply |
02/02/2024 | 3.18.0 | RULE-7816 | ADD | N/A | Created | |
02/02/2024 | 3.18.0 | RULE-7354 | ADD | N/A | Created | |
02/02/2024 | 3.18.0 | RULE-7353 | ADD | N/A | Created | |
02/02/2024 | 3.18.0 | RULE-7352 | ADD | N/A | Created | |
02/02/2024 | 3.18.0 | RULE-7351 | ADD | N/A | Created | |
02/02/2024 | 3.18.0 | RULE-7349 | ADD | N/A | Created | |
02/02/2024 | 3.18.0 | RULE-7265 | ADD | N/A | Created | |
02/02/2024 | 3.18.0 | RULE-7736 | ADD | N/A | Created | |
02/02/2024 | 3.18.0 | RULE-7892 | ADD | N/A | Created | |
02/02/2024 | 3.18.0 | RULE-7263 | ADD | N/A | Created | |
02/02/2024 | 3.18.0 | RULE-7262 | ADD | N/A | Created | |
02/02/2024 | 3.18.0 | RULE-7257 | ADD | N/A | Created | |
02/02/2024 | 3.18.0 | RULE-7256 | ADD | N/A | Created | |
02/02/2024 | 3.18.0 | RULE-7255 | ADD | N/A | Created | |
02/02/2024 | 3.18.0 | RULE-7254 | ADD | N/A | Created | |
02/02/2024 | 3.18.0 | RULE-7740 | ADD | N/A | Created | |
02/02/2024 | 3.18.0 | RULE-7896 | ADD | N/A | Created | |
02/02/2024 | 3.18.0 | RULE-7739 | ADD | N/A | Created | |
02/02/2024 | 3.18.0 | RULE-7895 | ADD | N/A | Created | |
02/02/2024 | 3.18.0 | RULE-7738 | ADD | N/A | Created | |
02/02/2024 | 3.18.0 | RULE-7894 | ADD | N/A | Created | |
02/02/2024 | 3.18.0 | RULE-7737 | ADD | N/A | Created | |
02/02/2024 | 3.18.0 | RULE-7893 | ADD | N/A | Created | |
03/27/2024 | 3.22.0 | EL-6-037-37 | UPDATE | Specification | STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Variable demographics on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 1, join to segment VARIABLE-DEMOGRAPHIC-ELG00003 by keeping records that satisfy the following criteria:1a. VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE <= last day of the DQ report month2a. VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE >= last day of the DQ report month OR missingOR1b. VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE is missing2b. VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE is missingSTEP 3: U.S. citizen immigration statusOf the MSIS IDs that meet the criteria from STEP 2, further refine the population by keeping MSIS IDs where:1. IMMIGRATION-STATUS = "3"STEP 4: Eligibility determinants on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 3, join to segment ELIGIBILITY-DETERMINANTS-ELG00005 by keeping records that satisfy the following criteria:1. PRIMARY-ELIGIBILITY-GROUP-IND = 12a. ELIGIBILITY-DETERMINANT-EFF-DATE <= last day of the DQ report month3a. ELIGIBILITY-DETERMINANT-END-DATE >= last day of the DQ report month OR missingOR2b. ELIGIBILITY-DETERMINANT-EFF-DATE is missing3b. ELIGIBILITY-DETERMINANT-END-DATE is missing"STEP 5: Restricted Benefits Code designationOf the MSIS IDs that meet the criteria from STEP 4, restrict to those where:1. RESTRICTED-BENEFITS-CODE is not “2” or "4"STEP 6: Calculate percentageDivide the count of unique MSIS IDs from STEP 5 by the count of unique MSIS IDs from STEP 4 | STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Variable demographics on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 1, join to segment VARIABLE-DEMOGRAPHIC-ELG00003 by keeping records that satisfy the following criteria:1a. VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE <= last day of the DQ report month2a. VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE >= last day of the DQ report month OR missingOR1b. VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE is missing2b. VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE is missingSTEP 3: U.S. citizen immigration statusOf the MSIS IDs that meet the criteria from STEP 2, further refine the population by keeping MSIS IDs where:1. IMMIGRATION-STATUS = "3"STEP 4: Eligibility determinants on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 3, join to segment ELIGIBILITY-DETERMINANTS-ELG00005 by keeping records that satisfy the following criteria:1. PRIMARY-ELIGIBILITY-GROUP-IND = 12a. ELIGIBILITY-DETERMINANT-EFF-DATE <= last day of the DQ report month3a. ELIGIBILITY-DETERMINANT-END-DATE >= last day of the DQ report month OR missingOR2b. ELIGIBILITY-DETERMINANT-EFF-DATE is missing3b. ELIGIBILITY-DETERMINANT-END-DATE is missing"STEP 5: Restricted Benefits Code designationOf the MSIS IDs that meet the criteria from STEP 4, restrict to those where:1. RESTRICTED-BENEFITS-CODE is not “2” or "4"STEP 6: Calculate percentageDivide the count of unique MSIS IDs from STEP 5 by the count of unique MSIS IDs from STEP 3 |
06/19/2024 | 3.27.0 | MIS-86-020-20 | UPDATE | Focus area | Managed care | N/A |
06/19/2024 | 3.27.0 | MIS-84-030-30 | UPDATE | Focus area | Managed care | N/A |
06/19/2024 | 3.27.0 | MIS-82-017-17 | UPDATE | Focus area | Managed care | N/A |
06/19/2024 | 3.27.0 | MIS-80-017-17 | UPDATE | Focus area | Managed care | N/A |
03/26/2024 | 3.22.0 | Data Quality Measures | UPDATE | Version text | 3.10.1 | 3.11.0 |
03/26/2024 | 3.22.0 | Data Quality Measures | UPDATE | Thresholds document | 253 | 280 |
03/26/2024 | 3.22.0 | Data Quality Measures | UPDATE | Measures specification | 251 | 281 |
03/26/2024 | 3.22.0 | Data Quality Measures | UPDATE | Threshold and measures combined | 252 | 282 |
09/12/2024 | 3.29.0 | COT.002.030 | UPDATE | Coding requirement | 1. When populated, a Diagnosis Code Flag is required2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL)3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL)4. Value must be a minimum of 3 characters5. Value must not contain a decimal point6. If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters8. When there is more than one diagnosis code on a claim, each value must be unique9. Conditional10. When populated, value cannot equal Diagnosis Code 1 (COT.002.027)11. When Diagnosis Code 1 (COT.002.027) is not populated, value should not be populated | 1. When populated, a Diagnosis Code Flag is required2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL)3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL)4. Value must be a minimum of 3 characters5. Value must not contain a decimal point6. If associated Diagnosis Code Flag value is "1" (ICD-9), value must not exceed 5 characters7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters8. When there is more than one diagnosis code on a claim, each value must be unique9. Conditional10. When populated, value cannot equal Diagnosis Code 1 (COT.002.027)11. When Diagnosis Code 1 (COT.002.027) is not populated, value should not be populated |
09/12/2024 | 3.29.0 | COT.002.027 | UPDATE | Coding requirement | 1. When populated, a Diagnosis Code Flag is required2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL)3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL)4. Value must be a minimum of 3 characters5. Value must not contain a decimal point6. If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters8. When there is more than one diagnosis code on a claim, each value must be unique9. Conditional10. If Type of Claim (COT.002.037) is in ("1", "3", "A", "C", "U", "W") then Diagnosis Code 1 (COT.002.027) must be populated. | 1. When populated, a Diagnosis Code Flag is required2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL)3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL)4. Value must be a minimum of 3 characters5. Value must not contain a decimal point6. If associated Diagnosis Code Flag value is "1" (ICD-9), value must not exceed 5 characters7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters8. When there is more than one diagnosis code on a claim, each value must be unique9. Conditional10. If Type of Claim (COT.002.037) is in [1,3,A,C,U,W] then Diagnosis Code 1 (COT.002.027) must be populated |
09/12/2024 | 3.29.0 | CLT.002.029 | UPDATE | Coding requirement | 1. When populated, a Diagnosis Code Flag is required2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL)3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL)4. Value must be a minimum of 3 characters5. Value must not contain a decimal point6. If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters8. When there is more than one diagnosis code on a claim, each value must be unique9. Conditional10. If Type of Claim (CLT.002.052) in ("1", "3", "A", "C", "U", "W") then value must be populated. | 1. When populated, a Diagnosis Code Flag is required2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL)3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL)4. Value must be a minimum of 3 characters5. Value must not contain a decimal point6. If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters8. When there is more than one diagnosis code on a claim, each value must be unique9. Conditional10. If Type of Claim (CLT.002.052) in [1,3,A,C,U,W] then value must be populated |
09/12/2024 | 3.29.0 | CIP.002.056 | UPDATE | Coding requirement | 1. When populated, a Diagnosis Code Flag is required2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL)3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL)4. Value must be a minimum of 3 characters5. Value must not contain a decimal point6. If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters8. When there is more than one diagnosis code on a claim, each value must be unique9. Conditional10. Value must not be populated when Diagnosis Code 8 (CIP.002.053) is not populated | 1. When populated, a Diagnosis Code Flag is required10. Value must not be populated when Diagnosis Code 8 (CIP.002.053) is not populated2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL)3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL)4. Value must be a minimum of 3 characters5. Value must not contain a decimal point6. If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters8. When there is more than one diagnosis code on a claim, each value must be unique9. Conditional |
09/12/2024 | 3.29.0 | CIP.002.032 | UPDATE | Coding requirement | 1. When populated, a Diagnosis Code Flag is required2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL)3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL)4. Value must be a minimum of 3 characters5. Value must not contain a decimal point6. If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters8. When there is more than one diagnosis code on a claim, each value must be unique9. Conditional10. If Type of Claim (CIP.002.100) in ("1", "3", "A", "C", "U", "W") then value must be populated. | 1. When populated, a Diagnosis Code Flag is required2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL)3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL)4. Value must be a minimum of 3 characters5. Value must not contain a decimal point6. If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters8. When there is more than one diagnosis code on a claim, each value must be unique9. Conditional10. If Type of Claim (CIP.002.100) in [1,3,A,C,U,W] then value must be populated |
11/15/2023 | 3.16.0 | RULE-7718 | ADD | N/A | Created | |
11/15/2023 | 3.16.0 | RULE-7719 | ADD | N/A | Created | |
11/15/2023 | 3.16.0 | RULE-7720 | ADD | N/A | Created | |
11/15/2023 | 3.16.0 | RULE-7721 | ADD | N/A | Created | |
11/15/2023 | 3.16.0 | RULE-7722 | ADD | N/A | Created | |
11/15/2023 | 3.16.0 | RULE-7711 | ADD | N/A | Created | |
11/15/2023 | 3.16.0 | RULE-7710 | ADD | N/A | Created | |
11/15/2023 | 3.16.0 | RULE-7713 | ADD | N/A | Created | |
11/15/2023 | 3.16.0 | RULE-7712 | ADD | N/A | Created | |
11/15/2023 | 3.16.0 | RULE-7717 | ADD | N/A | Created | |
11/15/2023 | 3.16.0 | RULE-7716 | ADD | N/A | Created | |
11/15/2023 | 3.16.0 | RULE-7715 | ADD | N/A | Created | |
11/15/2023 | 3.16.0 | RULE-7723 | ADD | N/A | Created | |
11/15/2023 | 3.16.0 | RULE-7724 | ADD | N/A | Created | |
11/15/2023 | 3.16.0 | RULE-7725 | ADD | N/A | Created | |
11/15/2023 | 3.16.0 | RULE-7726 | ADD | N/A | Created | |
11/15/2023 | 3.16.0 | RULE-7809 | ADD | N/A | Created | |
11/15/2023 | 3.16.0 | RULE-7801 | ADD | N/A | Created | |
11/15/2023 | 3.16.0 | RULE-7802 | ADD | N/A | Created | |
11/15/2023 | 3.16.0 | RULE-7803 | ADD | N/A | Created | |
11/15/2023 | 3.16.0 | RULE-7804 | ADD | N/A | Created | |
11/15/2023 | 3.16.0 | RULE-7797 | ADD | N/A | Created | |
11/15/2023 | 3.16.0 | RULE-7798 | ADD | N/A | Created | |
11/15/2023 | 3.16.0 | RULE-7799 | ADD | N/A | Created | |
11/15/2023 | 3.16.0 | RULE-7800 | ADD | N/A | Created | |
11/15/2023 | 3.16.0 | RULE-7808 | ADD | N/A | Created | |
11/15/2023 | 3.16.0 | RULE-7807 | ADD | N/A | Created | |
11/15/2023 | 3.16.0 | RULE-7806 | ADD | N/A | Created | |
11/15/2023 | 3.16.0 | RULE-7805 | ADD | N/A | Created | |
11/15/2023 | 3.16.0 | RULE-7793 | ADD | N/A | Created | |
11/15/2023 | 3.16.0 | RULE-7792 | ADD | N/A | Created | |
11/15/2023 | 3.16.0 | RULE-7791 | ADD | N/A | Created | |
11/15/2023 | 3.16.0 | RULE-7790 | ADD | N/A | Created | |
02/02/2024 | 3.18.0 | RULE-7370 | UPDATE | Focus area | N/A | Unwinding |
02/02/2024 | 3.18.0 | RULE-7196 | UPDATE | Adjustment type | All Adjustment Types | Non-void |
02/02/2024 | 3.18.0 | MIS-85-023-23 | UPDATE | Focus area | Managed care | N/A |
02/02/2024 | 3.18.0 | MIS-84-006-6 | UPDATE | Focus area | Managed care | N/A |
02/02/2024 | 3.18.0 | MIS-84-002-2 | UPDATE | Focus area | Managed care | N/A |
02/02/2024 | 3.18.0 | MIS-83-016-16 | UPDATE | Focus area | Managed care | N/A |
02/02/2024 | 3.18.0 | MIS-83-001-1 | UPDATE | Focus area | Managed care | N/A |
02/02/2024 | 3.18.0 | MIS-82-003-3 | UPDATE | Focus area | Managed care | N/A |
02/02/2024 | 3.18.0 | MIS-82-002-2 | UPDATE | Focus area | Managed care | N/A |
02/02/2024 | 3.18.0 | MIS-81-018-18 | UPDATE | Focus area | Managed care | N/A |
02/02/2024 | 3.18.0 | MIS-81-003-3 | UPDATE | Focus area | Managed care | N/A |
02/02/2024 | 3.18.0 | MIS-80-003-3 | UPDATE | Focus area | Managed care | N/A |
02/02/2024 | 3.18.0 | MIS-80-002-2 | UPDATE | Focus area | Managed care | N/A |
02/02/2024 | 3.18.0 | MIS-79-001-1 | UPDATE | Focus area | Managed care | N/A |
02/02/2024 | 3.18.0 | MCR-19-008-2 | UPDATE | Priority | High | N/A |
02/02/2024 | 3.18.0 | MCR-19-008-2 | UPDATE | Category | Utilization | N/A |
02/02/2024 | 3.18.0 | MCR-19-008-2 | UPDATE | For ta comprehensive | TA- Inferential | No |
02/02/2024 | 3.18.0 | MCR-19-008-2 | UPDATE | For ta inferential | Yes | No |
02/02/2024 | 3.18.0 | MCR-19-008-2 | UPDATE | Ta min | 0 | |
02/02/2024 | 3.18.0 | MCR-19-008-2 | UPDATE | Ta max | 0.05 | |
02/02/2024 | 3.18.0 | MCR-19-008-2 | UPDATE | Focus area | Managed care | N/A |
02/02/2024 | 3.18.0 | MCR-17-008-2 | UPDATE | Priority | High | N/A |
02/02/2024 | 3.18.0 | MCR-17-008-2 | UPDATE | Category | Utilization | N/A |
02/02/2024 | 3.18.0 | MCR-17-008-2 | UPDATE | For ta comprehensive | TA- Inferential | No |
02/02/2024 | 3.18.0 | MCR-17-008-2 | UPDATE | For ta inferential | Yes | No |
02/02/2024 | 3.18.0 | MCR-17-008-2 | UPDATE | Ta min | 0 | |
02/02/2024 | 3.18.0 | MCR-17-008-2 | UPDATE | Ta max | 0.05 | |
02/02/2024 | 3.18.0 | MCR-17-008-2 | UPDATE | Focus area | Managed care | N/A |
02/02/2024 | 3.18.0 | FFS-16-008-2 | UPDATE | Priority | High | N/A |
02/02/2024 | 3.18.0 | FFS-16-008-2 | UPDATE | Category | Utilization | N/A |
02/02/2024 | 3.18.0 | FFS-16-008-2 | UPDATE | For ta comprehensive | TA- Inferential | No |
02/02/2024 | 3.18.0 | FFS-16-008-2 | UPDATE | For ta inferential | Yes | No |
02/02/2024 | 3.18.0 | FFS-16-008-2 | UPDATE | Ta min | 0 | |
02/02/2024 | 3.18.0 | FFS-16-008-2 | UPDATE | Ta max | 0.05 | |
02/02/2024 | 3.18.0 | FFS-14-008-2 | UPDATE | Priority | High | N/A |
02/02/2024 | 3.18.0 | FFS-14-008-2 | UPDATE | Category | Utilization | N/A |
02/02/2024 | 3.18.0 | FFS-14-008-2 | UPDATE | For ta comprehensive | TA- Inferential | No |
02/02/2024 | 3.18.0 | FFS-14-008-2 | UPDATE | For ta inferential | Yes | No |
02/02/2024 | 3.18.0 | FFS-14-008-2 | UPDATE | Ta min | 0 | |
02/02/2024 | 3.18.0 | FFS-14-008-2 | UPDATE | Ta max | 0.05 | |
02/01/2024 | 3.18.0 | Data Quality Measures | UPDATE | Version text | 3.10.0 | 3.10.1 |
09/12/2024 | 3.29.0 | CRX.002.099 | UPDATE | Coding requirement | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, value must have an associated Third Party Coinsurance Amount4. Conditional | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, value must have an associated Third Party Coinsurance Amount4. Conditional |
09/12/2024 | 3.29.0 | CRX.002.025 | UPDATE | Coding requirement | 1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory6. If value is in [‘0’, ‘5’, ‘6’ ], then associated Adjustment ICN must not be populated7. If value is in [‘4’, ‘1’] then Adjustment ICN must be populated8. Value must equal ‘1’, when associated Claim Status equals ‘686’ | 1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [1,3,5,A,C,E,U,W,Y], then value must be in [0,1,4]3. If associated Type of Claim value is in [4,D,X], then value must be in [5,6]4. Value must be 1 character5. Mandatory6. If value is in [0,5,6], then associated Adjustment ICN must not be populated7. If value is in [4,1] then Adjustment ICN must be populated8. Value must equal "1", when associated Claim Status equals "686" |
09/12/2024 | 3.29.0 | COT.002.025 | UPDATE | Coding requirement | 1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory6. If value is in [‘0’, ‘5’, ‘6’ ], then associated Adjustment ICN must not be populated7. If value is in [‘4’, ‘1’] then Adjustment ICN must be populated8. Value must equal ‘1’, when associated Claim Status equals ‘686’ | 1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in[1,3,5,A,C,E,U,W,Y], then value must be in [0,1,4]3. If associated Type of Claim value is in [4,D,X], then value must be in [5,6]4. Value must be 1 character5. Mandatory6. If value is in [0,5,6], then associated Adjustment ICN must not be populated7. If value is in [4,1] then Adjustment ICN must be populated8. Value must equal "1", when associated Claim Status equals "686" |
09/12/2024 | 3.29.0 | CLT.002.025 | UPDATE | Coding requirement | 1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory6. If value is in [‘0’, ‘5’, ‘6’ ], then associated Adjustment ICN must not be populated7. If value is in [‘4’, ‘1’] then Adjustment ICN must be populated8. Value must equal ‘1’, when associated Claim Status equals ‘686’ | 1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [1,3,5,A,C,E,U,W,Y], then value must be in [0,1,4]3. If associated Type of Claim value is in [4,D,X], then value must be in [5,6]4. Value must be 1 character5. Mandatory6. If value is in [0,5,6], then associated Adjustment ICN must not be populated7. If value is in [4,1] then Adjustment ICN must be populated8. Value must equal "1", when associated Claim Status equals "686" |
09/12/2024 | 3.29.0 | CIP.002.026 | UPDATE | Coding requirement | 1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory6. If value is in [‘0’, ‘5’, ‘6’ ], then associated Adjustment ICN must not be populated7. If value is in [‘4’, ‘1’] then Adjustment ICN must be populated8. Value must equal ‘1’, when associated Claim Status equals ‘686’ | 1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [1,3,5,A,C,E,U,W,Y], then value must be in [0,1,4]3. If associated Type of Claim value is in [4,D,X], then value must be in [5,6]4. Value must be 1 character5. Mandatory6. If value is in [0,5,6], then associated Adjustment ICN must not be populated7. If value is in [4,1] then Adjustment ICN must be populated8. Value must equal "1", when associated Claim Status equals "686" |
09/12/2024 | 3.29.0 | TPL.001.012 | UPDATE | Coding requirement | 1. Value must be in SSN Indicator List (VVL)2. Value must be 1 character3. Mandatory4. When populated, value must equal SSN Indicator (ELG.001.012) | 1. Value must be in SSN Indicator List (VVL)2. Value must be 1 character3. Mandatory |
09/12/2024 | 3.29.0 | COT.003.189 | UPDATE | Coding requirement | 1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ("Z","3","C",'W',"2","B","V","4","D","X") then value may match (PRV.005.081) Provider Identifier or4. When Type of Claim not in ("Z","3","C",'W',"2","B","V","4","D","X") then value may match (PRV.002.019) Submitting State Provider ID5. When Type of Claim in ["1","3","A","C"] then associated Provider Medicaid Enrollment Status Code (PRV.007.100) must be in "01", "02", "03", "04", "05", "06"] (active) | 1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in [Z,3,C,W,2,B,V,4,D,X], then value may match (PRV.005.081) Provider Identifier or4. When Type of Claim not in [Z,3,C,W,2,B,V,4,D,X], then value may match (PRV.002.019) Submitting State Provider ID5. When Type of Claim in [1,3,A,C] then associated Provider Medicaid Enrollment Status Code (PRV.007.100) must be in [01,02,03,04,05,06] (active) |
09/12/2024 | 3.29.0 | ELG.005.091 | UPDATE | Coding requirement | 1. Value must be in SSI State Supplement Status Code List (VVL)2. Value must be 3 characters3. (individual not receiving Federal SSI)If value is "001" or "002", then SSI Status (ELG.005.092) must be "001" or "002"4. (Individual not receiving Federal SSI)If value is "001" or "002", then SSI Indicator (ELG.005.090) must be "1"5. Value must not be populated or must be "000" when SSI Status (ELG.005.092) is not populated or is "000" | 1. Value must be in SSI State Supplement Status Code List (VVL)2. Value must be 3 characters3. (individual not receiving Federal SSI) If value is "001" or "002", then SSI Status (ELG.005.092) must be "001" or "002"4. (Individual not receiving Federal SSI)If value is "001" or "002", then SSI Indicator (ELG.005.090) must be "1"5. Value must not be populated or must be "000" when SSI Status (ELG.005.092) is not populated or is "000" |
09/12/2024 | 3.29.0 | CLT.003.212 | UPDATE | Coding requirement | 1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID5. When Type of Claim in ['1','3','A','C’] then associated Provider Medicaid Enrollment Status Code (PRV.007.100) must be in ['01', '02', '03', '04', '05', '06'] (active) | 1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in [Z,3,C,W,2,B,V,4,D,X] then value may match (PRV.005.081) Provider Identifier or4. When Type of Claim not in [Z,3,C,W,2,B,V,4,D,X] then value may match (PRV.002.019) Submitting State Provider ID |
09/12/2024 | 3.29.0 | CLT.002.150 | UPDATE | Coding requirement | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Split Claim Indicator List (VVL).4. Conditional | 1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in Split Claim Indicator List (VVL)4. Conditional |
09/12/2024 | 3.29.0 | CIP.003.260 | UPDATE | Coding requirement | 1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID5. When Type of Claim in ['1','3','A','C’] then associated Provider Medicaid Enrollment Status Code (PRV.007.100) must be in ['01', '02', '03', '04', '05', '06'] (active) | 1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in (Z,3,C,W,2,B,V,4,D,X) then value may match (PRV.005.081) Provider Identifier or4. When Type of Claim not in (Z,3,C,W,2,B,V,4,D,X) then value may match (PRV.002.019) Submitting State Provider ID5. When Type of Claim in [1,3,A,C] then associated Provider Medicaid Enrollment Status Code (PRV.007.100) must be in [01,02,03,04,05,06] (active) |
09/12/2024 | 3.29.0 | CIP.002.203 | UPDATE | Coding requirement | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Split Claim Indicator List (VVL).4. Conditional | 1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in Split Claim Indicator List (VVL)4. Conditional |
09/12/2024 | 3.29.0 | COT.003.190 | UPDATE | Coding requirement | 1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. When Type of Claim (COT.002.037) not in ('3','C','W') then value must match Provider Identifier (PRV.005.081)5. Value must exist in the NPPES NPI data file | 1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to "2"3. Value must exist in the NPPES NPI data file4. Conditional5. When Type of Claim (COT.002.037) not in [3,C,W]. then value must match Provider Identifier (PRV.005.081)6. When Type of Claim is in [1,3,A,C], then value must be populated7.When Type of Claim is in [1,3,A,C] and value is not populated, Servicing Provider Number (COT.003.189) must be populated |
09/12/2024 | 3.29.0 | CLT.003.213 | UPDATE | Coding requirement | 1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. When Type of Claim (CLT.002.052) not in ('3','C','W') then value must match Provider Identifier (PRV.005.081)5. Value must exist in the NPPES NPI data file | 1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Value must have an associated Provider Identifier Type equal to "2"3. Conditional4. When Type of Claim (CLT.002.052) not in [3,C,W] then value must match Provider Identifier (PRV.005.081) |
09/12/2024 | 3.29.0 | CIP.003.261 | UPDATE | Coding requirement | 1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. Value must exist in the NPPES NPI data file5. When Type of Claim is in ['1','3','A','C'], then value must be populated | 1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to "2"3. Value must exist in the NPPES NPI data file4. Conditional5. When Type of Claim is in [1,3,A,C], then value must be populated |
09/12/2024 | 3.29.0 | CRX.002.075 | UPDATE | Coding requirement | 1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Mandatory4. Value must exist in the NPPES NPI data file5. NPPES Entity Type Code associate with this NPI must equal ‘1’ (Individual) | 1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to "2"3. Value must exist in the NPPES NPI data file4. Mandatory5. NPPES Entity Type Code associate with this NPI must equal '1' (Individual) |
09/12/2024 | 3.29.0 | CIP.003.265 | UPDATE | Coding requirement | 1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. Value must exist in the NPPES NPI data file | 1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to "2"3. Value must exist in the NPPES NPI data file4. Conditional5. When Type of Claim is in [1,3,A,C], then value must be populated |
09/12/2024 | 3.29.0 | COT.003.169 | UPDATE | Coding requirement | 1. When populated, there must be a corresponding Procedure Code Flag2. If associated Procedure Code Flag List (VVL) value indicates an CPT-4 encoding '01', then value must be a valid CPT-4 procedure code3. If associated Procedure Code Flag List (VVL) value indicates an "Other" encoding '10-87', then State must provide T-MSIS system with State-specific procedure code list, and value must be a valid State-specific procedure code4. If associated Procedure Code Flag List (VVL) value indicates an HCPCS encoding '06', then value must be a valid HCPCS code5. Value must be 8 characters or less6. Value must be in Procedure Code List (VVL)7. Conditional | 1. When populated, there must be a corresponding Procedure Code Flag2. If associated Procedure Code Flag List (VVL) value indicates an CPT-4 encoding "01", then value must be a valid CPT-4 procedure code3. If associated Procedure Code Flag List (VVL) value indicates "Other" encoding "10-87", then State must provide T-MSIS system with State-specific procedure code list,and value must be a valid State-specific procedure code4. If associated Procedure Code Flag List (VVL) value indicates an HCPCS encoding "06", then value must be a valid HCPCS code5. Value must be 8 characters or less6. Value must be in Procedure Code List (VVL)7. Conditional |
09/12/2024 | 3.29.0 | CRX.002.101 | UPDATE | Coding requirement | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, must have an associated Third Party Copayment Amount4. Situational | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, must have an associated Third Party Copayment Amount4. Situational |
11/15/2023 | 3.16.0 | RULE-7411 | UPDATE | Ta min | 0.05 | 0 |
11/15/2023 | 3.16.0 | RULE-7408 | UPDATE | Ta min | 0.01 | 0 |
11/15/2023 | 3.16.0 | RULE-7407 | UPDATE | Ta min | 0.01 | 0 |
11/15/2023 | 3.16.0 | RULE-7371 | UPDATE | Ta min | 0.02 | 0 |
11/15/2023 | 3.16.0 | RULE-7370 | UPDATE | Ta min | 0.02 | 0 |
02/02/2024 | 3.18.0 | RULE-7366 | UPDATE | Focus area | N/A | Unwinding |
02/02/2024 | 3.18.0 | RULE-7423 | UPDATE | Focus area | N/A | Unwinding |
06/19/2024 | 3.27.0 | MCR-59R-004-16 | UPDATE | Focus area | Managed care | N/A |
06/19/2024 | 3.27.0 | MCR-59R-003-15 | UPDATE | Focus area | Managed care | N/A |
06/19/2024 | 3.27.0 | MCR-59R-002-14 | UPDATE | Focus area | Managed care | N/A |
06/19/2024 | 3.27.0 | MCR-59R-001-13 | UPDATE | Focus area | Managed care | N/A |
06/19/2024 | 3.27.0 | MCR-56R-001-1 | UPDATE | Focus area | Managed care | N/A |
06/19/2024 | 3.27.0 | EXP-41R-001-1 | UPDATE | Focus area | Managed care | N/A |
06/19/2024 | 3.27.0 | EXP-22R-009-9 | UPDATE | Focus area | Managed care | N/A |
06/19/2024 | 3.27.0 | EXP-37R-001-1-2 | UPDATE | Focus area | Managed care | N/A |
06/19/2024 | 3.27.0 | EXP-33R-001-1 | UPDATE | Focus area | Managed care | N/A |
06/19/2024 | 3.27.0 | EXP-29R-001-1 | UPDATE | Focus area | Managed care | N/A |
06/19/2024 | 3.27.0 | MCR-59P-004-16 | UPDATE | Focus area | Managed care | N/A |
06/19/2024 | 3.27.0 | MCR-59P-003-15 | UPDATE | Focus area | Managed care | N/A |
06/19/2024 | 3.27.0 | MCR-59P-002-14 | UPDATE | Focus area | Managed care | N/A |
06/19/2024 | 3.27.0 | MCR-59P-001-13 | UPDATE | Focus area | Managed care | N/A |
06/19/2024 | 3.27.0 | MCR-56P-001-1 | UPDATE | Focus area | Managed care | N/A |
06/19/2024 | 3.27.0 | EXP-41P-001-1 | UPDATE | Focus area | Managed care | N/A |
06/19/2024 | 3.27.0 | EXP-22P-009-9 | UPDATE | Focus area | Managed care | N/A |
06/19/2024 | 3.27.0 | EXP-37P-001-1-2 | UPDATE | Focus area | Managed care | N/A |
06/19/2024 | 3.27.0 | EXP-33P-001-1 | UPDATE | Focus area | Managed care | N/A |
06/19/2024 | 3.27.0 | EXP-29P-001-1 | UPDATE | Focus area | Managed care | N/A |
11/15/2023 | 3.16.0 | RULE-7641 | UPDATE | Measure name | % of record segments with a valid Dual Eligible Code that have a missing value for Medicare HIC Number or Medicare Beneficiary Identifier for the same period of time | % of record segments with a valid Dual Eligible Code that have a missing value for Medicare HIC Number and Medicare Beneficiary Identifier for the same period of time |
06/19/2024 | 3.27.0 | ALL-16-015-15 | UPDATE | Threshold minimum | TBD | N/A |
06/19/2024 | 3.27.0 | ALL-16-015-15 | UPDATE | Threshold maximum | TBD | N/A |
06/19/2024 | 3.27.0 | ALL-16-015-15 | UPDATE | Annotation | Calculate the percentage of RX claim lines with XIX-MBESCBES-CATEGORY-OF-SERVICE = “14”, “35”, “42” or “44” that are linked to an MSIS ID where SEX is "M" | N/A |
06/19/2024 | 3.27.0 | ALL-16-015-15 | UPDATE | Specification | STEP 1: Active non-duplicate RX records during DQ report monthDefine the RX records universe at the line level by importing lines that satisfy the following criteria:For Headers:1. Reporting Period from 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: Non-missing prescription fill dateOf the claim lines that meet the criteria from STEP 1, restrict to non-missing PRESCRIPTION-FILL-DATESTEP 3: Link claims to primary demographicsKeep all claims from STEP 2 for which the MSIS ID on the claim is also found on a PRIMARY-DEMOGRAPHICS-ELG00002 segment, where the following is true:1. Claims PRESCRIPTION-FILL-DATE>= PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE 2. Claims PRESCRIPTION-FILL-DATE<= PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE OR missingSTEP 4: Non-missing SexOf the claims that meet the criteria from STEP 3, restrict to non-missing SEXSTEP 5: XIX category of serviceOf claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. XIX-MBESCBES-CATEGORY-OF-SERVICE = “14”, “35”, “42” or “44”STEP 6: Sex is "M"Of claims that meet the criteria from STEP 5, further restrict them by the following criteria:1. SEX = "M"STEP 7: Calculate percentageDivide the count of claim lines from STEP 6 by the count of claim lines from STEP 5 | N/A |
06/19/2024 | 3.27.0 | ALL-16-014-14 | UPDATE | Threshold minimum | TBD | N/A |
06/19/2024 | 3.27.0 | ALL-16-014-14 | UPDATE | Threshold maximum | TBD | N/A |
06/19/2024 | 3.27.0 | ALL-16-014-14 | UPDATE | Annotation | Calculate the percentage of OT claim lines with XIX-MBESCBES-CATEGORY-OF-SERVICE = “14”, “35”, “42” or “44” that are linked to an MSIS ID where SEX is "M" | N/A |
06/19/2024 | 3.27.0 | ALL-16-014-14 | UPDATE | Specification | STEP 1: Active non-duplicate OT records during DQ report monthDefine the OT records universe at the line level by importing lines that satisfy the following criteria:For Headers:1. Reporting Period from 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: Non-missing beginning date of serviceOf the claim lines that meet the criteria from STEP 1, restrict to non-missing BEGINNING-DATE-OF-SERVICESTEP 3: Link claims to primary demographicsKeep all claims from STEP 2 for which the MSIS ID on the claim is also found on a PRIMARY-DEMOGRAPHICS-ELG00002 segment, where the following is true:1. Claims BEGINNING-DATE-OF-SERVICE>= PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE 2. Claims BEGINNING-DATE-OF-SERVICE <= PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE OR missingSTEP 4: Non-missing SexOf the claims that meet the criteria from STEP 3, restrict to non-missing SEXSTEP 5: XIX category of serviceOf claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. XIX-MBESCBES-CATEGORY-OF-SERVICE = “14”, “35”, “42” or “44”STEP 6: Sex is "M"Of claims that meet the criteria from STEP 5, further restrict them by the following criteria:1. SEX = "M"STEP 7: Calculate percentageDivide the count of claim lines from STEP 6 by the count of claim lines from STEP 5 | N/A |
06/19/2024 | 3.27.0 | ALL-16-013-13 | UPDATE | Threshold minimum | TBD | N/A |
06/19/2024 | 3.27.0 | ALL-16-013-13 | UPDATE | Threshold maximum | TBD | N/A |
06/19/2024 | 3.27.0 | ALL-16-013-13 | UPDATE | Annotation | Calculate the percentage of LT claim lines with XIX-MBESCBES-CATEGORY-OF-SERVICE = “14”, “35”, “42” or “44” that are linked to an MSIS ID where SEX is "M" | N/A |
06/19/2024 | 3.27.0 | ALL-16-013-13 | UPDATE | Specification | STEP 1: Active non-duplicate LT records during DQ report monthDefine the LT records universe at the line level by importing lines that satisfy the following criteria:For Headers:1. Reporting Period from 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: Non-missing beginning date of serviceOf the claim lines that meet the criteria from STEP 1, restrict to non-missing BEGINNING-DATE-OF-SERVICESTEP 3: Link claims to primary demographicsKeep all claims from STEP 2 for which the MSIS ID on the claim is also found on a PRIMARY-DEMOGRAPHICS-ELG00002 segment, where the following is true:1. Claims BEGINNING-DATE-OF-SERVICE>= PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE 2. Claims BEGINNING-DATE-OF-SERVICE <= PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE OR missingSTEP 4: Non-missing SexOf the claims that meet the criteria from STEP 3, restrict to non-missing SEXSTEP 5: XIX category of serviceOf claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. XIX-MBESCBES-CATEGORY-OF-SERVICE = “14”, “35”, “42” or “44”STEP 6: Sex is "M"Of claims that meet the criteria from STEP 5, further restrict them by the following criteria:1. SEX = "M"STEP 7: Calculate percentageDivide the count of claim lines from STEP 6 by the count of claim lines from STEP 5 | N/A |
06/19/2024 | 3.27.0 | ALL-16-012-12 | UPDATE | Threshold minimum | TBD | N/A |
06/19/2024 | 3.27.0 | ALL-16-012-12 | UPDATE | Threshold maximum | TBD | N/A |
06/19/2024 | 3.27.0 | ALL-16-012-12 | UPDATE | Annotation | Calculate the percentage of IP claim lines with XIX-MBESCBES-CATEGORY-OF-SERVICE= “14”, “35”, “42” or “44” that are linked to an MSIS ID where SEX is "M" | N/A |
06/19/2024 | 3.27.0 | ALL-16-012-12 | UPDATE | Specification | STEP 1: Active non-duplicate IP records during DQ report monthDefine the IP records universe at the line level by importing lines that satisfy the following criteria:For Headers:1. Reporting Period from 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: Non-missing admission dateOf the claim lines that meet the criteria from STEP 1, restrict to non-missing ADMISSION-DATESTEP 3: Link claims to primary demographicsKeep all claims from STEP 2 for which the MSIS ID on the claim is also found on a PRIMARY-DEMOGRAPHICS-ELG00002 segment, where the following is true:1. Claims ADMISSION-DATE>= PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE 2. Claims ADMISSION-DATE <= PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE OR missingSTEP 4: Non-missing SexOf the claims that meet the criteria from STEP 3, restrict to non-missing SEXSTEP 5: XIX category of serviceOf claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. XIX-MBESCBES-CATEGORY-OF-SERVICE = “14”, “35”, “42” or “44”STEP 6: Sex is "M"Of claims that meet the criteria from STEP 5, further restrict them by the following criteria:1. SEX = "M"STEP 7: Calculate percentageDivide the count of claim lines from STEP 6 by the count of claim lines from STEP 5 | N/A |
06/19/2024 | 3.27.0 | ALL-16-011-11 | UPDATE | Measure name | % of claim lines with TYPE-OF-SERVICE= “025” or “085” (LT) linked to an MSIS ID where SEX = “M” | % of claim lines with TYPE-OF-SERVICE= “025” or “085” (OT) linked to an MSIS ID where SEX = “M” |
06/19/2024 | 3.27.0 | ALL-16-011-11 | UPDATE | Annotation | Calculate the percentage of LT claim lines with TYPE-OF-SERVICE= "025" or "085” that are linked to an MSIS ID where SEX is "M" | Calculate the percentage of OT claim lines with TYPE-OF-SERVICE= "025" or "085” that are linked to an MSIS ID where SEX is "M" |
06/19/2024 | 3.27.0 | ALL-16-011-11 | UPDATE | Specification | STEP 1: Active non-duplicate LT records during DQ report monthDefine the LT records universe at the line level by importing lines that satisfy the following criteria:For Headers:1. Reporting Period from 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: Non-missing beginning date of serviceOf the claim lines that meet the criteria from STEP 1, restrict to non-missing BEGINNING-DATE-OF-SERVICESTEP 3: Link claims to primary demographicsKeep all claims from STEP 2 for which the MSIS ID on the claim is also found on a PRIMARY-DEMOGRAPHICS-ELG00002 segment, where the following is true:1. Claims BEGINNING-DATE-OF-SERVICE>= PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE 2. Claims BEGINNING-DATE-OF-SERVICE <= PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE OR missingSTEP 4: Non-missing SexOf the claims that meet the criteria from STEP 3, restrict to non-missing SEXSTEP 5: Nurse-midwife service or Prenatal care and pre-pregnancy family planning services and supplies type of serviceOf claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-SERVICE = "025" or "085"STEP 6: Sex is "M"Of claims that meet the criteria from STEP 5, further restrict them by the following criteria:1. SEX = "M"STEP 7: Calculate percentageDivide the count of claim lines from STEP 6 by the count of claim lines from STEP 5 | STEP 1: Active non-duplicate OT records during DQ report monthDefine the OT records universe at the line level by importing lines that satisfy the following criteria:For Headers:1. Reporting Period from 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: Non-missing beginning date of serviceOf the claim lines that meet the criteria from STEP 1, restrict to non-missing BEGINNING-DATE-OF-SERVICESTEP 3: Link claims to primary demographicsKeep all claims from STEP 2 for which the MSIS ID on the claim is also found on a PRIMARY-DEMOGRAPHICS-ELG00002 segment, where the following is true:1. Claims BEGINNING-DATE-OF-SERVICE>= PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE 2. Claims BEGINNING-DATE-OF-SERVICE <= PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE OR missingSTEP 4: Non-missing SexOf the claims that meet the criteria from STEP 3, restrict to non-missing SEXSTEP 5: Nurse-midwife service or Prenatal care and pre-pregnancy family planning services and supplies type of serviceOf claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-SERVICE = "025" or "085"STEP 6: Sex is "M"Of claims that meet the criteria from STEP 5, further restrict them by the following criteria:1. SEX = "M"STEP 7: Calculate percentageDivide the count of claim lines from STEP 6 by the count of claim lines from STEP 5 |
06/19/2024 | 3.27.0 | ALL-16-010-10 | UPDATE | Threshold minimum | TBD | N/A |
06/19/2024 | 3.27.0 | ALL-16-010-10 | UPDATE | Threshold maximum | TBD | N/A |
06/19/2024 | 3.27.0 | ALL-16-010-10 | UPDATE | Annotation | Calculate the percentage of RX claim lines with TYPE-OF-SERVICE= “086” that are linked to an MSIS ID where SEX is "M" | N/A |
06/19/2024 | 3.27.0 | ALL-16-010-10 | UPDATE | Specification | STEP 1: Active non-duplicate RX records during DQ report monthDefine the RX records universe at the line level by importing lines that satisfy the following criteria:For Headers:1. Reporting Period from 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: Non-missing prescription fill dateOf the claim lines that meet the criteria from STEP 1, restrict to non-missing PRESCRIPTION-FILL-DATESTEP 3: Link claims to primary demographicsKeep all claims from STEP 2 for which the MSIS ID on the claim is also found on a PRIMARY-DEMOGRAPHICS-ELG00002 segment, where the following is true:1. Claims PRESCRIPTION-FILL-DATE>= PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE 2. Claims PRESCRIPTION-FILL-DATE<= PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE OR missingSTEP 4: Non-missing SexOf the claims that meet the criteria from STEP 3, restrict to non-missing SEXSTEP 5: Other Pregnancy-related Procedures type of serviceOf claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-SERVICE = "086"STEP 6: Sex is "M"Of claims that meet the criteria from STEP 5, further restrict them by the following criteria:1. SEX = "M"STEP 7: Calculate percentageDivide the count of claim lines from STEP 6 by the count of claim lines from STEP 5 | N/A |
06/19/2024 | 3.27.0 | ALL-16-009-9 | UPDATE | Threshold minimum | TBD | N/A |
06/19/2024 | 3.27.0 | ALL-16-009-9 | UPDATE | Threshold maximum | TBD | N/A |
06/19/2024 | 3.27.0 | ALL-16-009-9 | UPDATE | Annotation | Calculate the percentage of IP claim lines with TYPE-OF-SERVICE= “086” that are linked to an MSIS ID where SEX is "M" | N/A |
06/19/2024 | 3.27.0 | ALL-16-009-9 | UPDATE | Specification | STEP 1: Active non-duplicate IP records during DQ report monthDefine the IP records universe at the line level by importing lines that satisfy the following criteria:For Headers:1. Reporting Period from 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: Non-missing admission dateOf the claim lines that meet the criteria from STEP 1, restrict to non-missing ADMISSION-DATESTEP 3: Link claims to primary demographicsKeep all claims from STEP 2 for which the MSIS ID on the claim is also found on a PRIMARY-DEMOGRAPHICS-ELG00002 segment, where the following is true:1. Claims ADMISSION-DATE>= PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE 2. Claims ADMISSION-DATE <= PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE OR missingSTEP 4: Non-missing SexOf the claims that meet the criteria from STEP 3, restrict to non-missing SEXSTEP 5: Other Pregnancy-related Procedures type of serviceOf claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-SERVICE = "086"STEP 6: Sex is "M"Of claims that meet the criteria from STEP 5, further restrict them by the following criteria:1. SEX = "M"STEP 7: Calculate percentageDivide the count of claim lines from STEP 6 by the count of claim lines from STEP 5 | N/A |
06/19/2024 | 3.27.0 | EL-3-029-38 | UPDATE | Priority | N/A | High |
06/19/2024 | 3.27.0 | EL-3-029-38 | UPDATE | Category | N/A | Beneficiary eligibility |
06/19/2024 | 3.27.0 | EL-3-029-38 | UPDATE | For ta comprehensive | No | TA- Inferential |
06/19/2024 | 3.27.0 | EL-3-029-38 | UPDATE | For ta inferential | No | Yes |
06/19/2024 | 3.27.0 | EL-3-029-38 | UPDATE | Ta min | 0 | |
06/19/2024 | 3.27.0 | EL-3-029-38 | UPDATE | Ta max | 0.05 | |
06/19/2024 | 3.27.0 | EL-3-029-38 | UPDATE | Threshold minimum | TBD | 0 |
06/19/2024 | 3.27.0 | EL-3-029-38 | UPDATE | Threshold maximum | TBD | 0.05 |
06/19/2024 | 3.27.0 | EL-3-028-37 | UPDATE | Priority | N/A | High |
06/19/2024 | 3.27.0 | EL-3-028-37 | UPDATE | Category | N/A | Beneficiary demographics |
06/19/2024 | 3.27.0 | EL-3-028-37 | UPDATE | For ta comprehensive | No | TA- Inferential |
06/19/2024 | 3.27.0 | EL-3-028-37 | UPDATE | For ta inferential | No | Yes |
06/19/2024 | 3.27.0 | EL-3-028-37 | UPDATE | Ta min | 0 | |
06/19/2024 | 3.27.0 | EL-3-028-37 | UPDATE | Ta max | 0.05 | |
06/19/2024 | 3.27.0 | EL-3-028-37 | UPDATE | Threshold minimum | TBD | 0 |
06/19/2024 | 3.27.0 | EL-3-028-37 | UPDATE | Threshold maximum | TBD | 0.05 |
06/19/2024 | 3.27.0 | EXP-13-004_1-7 | UPDATE | Priority | N/A | High |
06/19/2024 | 3.27.0 | EXP-13-004_1-7 | UPDATE | For ta comprehensive | No | TA- Inferential |
06/19/2024 | 3.27.0 | EXP-13-004_1-7 | UPDATE | For ta inferential | No | Yes |
06/19/2024 | 3.27.0 | EXP-13-004_1-7 | UPDATE | Ta min | 0 | |
06/19/2024 | 3.27.0 | EXP-13-004_1-7 | UPDATE | Ta max | 0.1 | |
06/19/2024 | 3.27.0 | EXP-13-004_1-7 | UPDATE | Threshold minimum | TBD | 0 |
06/19/2024 | 3.27.0 | EXP-13-004_1-7 | UPDATE | Threshold maximum | TBD | 0.1 |
06/19/2024 | 3.27.0 | EXP-13-003_1-6 | UPDATE | Priority | N/A | High |
06/19/2024 | 3.27.0 | EXP-13-003_1-6 | UPDATE | For ta comprehensive | No | TA- Inferential |
06/19/2024 | 3.27.0 | EXP-13-003_1-6 | UPDATE | For ta inferential | No | Yes |
06/19/2024 | 3.27.0 | EXP-13-003_1-6 | UPDATE | Ta min | 0 | |
06/19/2024 | 3.27.0 | EXP-13-003_1-6 | UPDATE | Ta max | 0.1 | |
06/19/2024 | 3.27.0 | EXP-13-003_1-6 | UPDATE | Threshold minimum | TBD | 0 |
06/19/2024 | 3.27.0 | EXP-13-003_1-6 | UPDATE | Threshold maximum | TBD | 0.1 |
11/15/2023 | 3.16.0 | RULE-7706 | UPDATE | Adjustment type | Original | Non-void |
11/15/2023 | 3.16.0 | RULE-7702 | UPDATE | Adjustment type | Original | Non-void |
11/15/2023 | 3.16.0 | RULE-7201 | UPDATE | Adjustment type | Non-void | All Adjustment Types |
11/15/2023 | 3.16.0 | RULE-7200 | UPDATE | Adjustment type | Non-void | All Adjustment Types |
11/15/2023 | 3.16.0 | RULE-7199 | UPDATE | Adjustment type | Non-void | All Adjustment Types |
11/15/2023 | 3.16.0 | RULE-7198 | UPDATE | Adjustment type | Non-void | All Adjustment Types |
11/15/2023 | 3.16.0 | RULE-7197 | UPDATE | Adjustment type | Non-void | All Adjustment Types |
11/15/2023 | 3.16.0 | RULE-7196 | UPDATE | Adjustment type | Non-void | All Adjustment Types |
11/15/2023 | 3.16.0 | RULE-7195 | UPDATE | Adjustment type | Non-void | All Adjustment Types |
11/15/2023 | 3.16.0 | RULE-7194 | UPDATE | Adjustment type | Non-void | All Adjustment Types |
06/19/2024 | 3.27.0 | MCR-9-019-21 | UPDATE | Threshold minimum | TBD | N/A |
06/19/2024 | 3.27.0 | MCR-9-019-21 | UPDATE | Threshold maximum | TBD | N/A |
06/19/2024 | 3.27.0 | MCR-9-019-21 | UPDATE | Annotation | Calculate the percentage of Comprehensive MCO capitation payments with a non-missing plan id that do not have a corresponding managed care participation Comprehensive MCO plan | N/A |
06/19/2024 | 3.27.0 | MCR-9-019-21 | UPDATE | Specification | STEP 1: Active non-duplicate paid OT claims during report monthDefine 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 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 Capitation Payment: Original, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "2"2. ADJUSTMENT-IND = "0"STEP 3: Type of serviceOf the claims that meet the criteria from STEP 2, further restrict them by the following criteria: 1. TYPE-OF-SERVICE = "119"STEP 4: Non-missing plan idOf the claims that meet the criteria from STEP 3, further restrict them by the following criteria: 1. PLAN-ID-NUMBER is not missingSTEP 5: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 6: Managed care enrollment on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 5, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 7: No managed care participation Comprehensive MCO planOf the claim lines that meet the criteria from STEP 4, further restrict them by attempting to merge them with the data from STEP 6 and keeping those that satisfy the following criteria:1a. PLAN-ID-NUMBER = MANAGED-CARE-PLAN-ID2a. MSIS-IDENTIFICATION-NUM matches 3a. MANAGED-CARE-PLAN-TYPE does NOT equal “01”, “04”, or “17” for any records where 1a and 2a are satisfiedORIt is not the case that:1b. PLAN-ID-NUMBER = MANAGED-CARE-PLAN-ID2b. MSIS-IDENTIFICATION-NUM matches STEP 8: Calculate the percentage for the measureDivide the count of claims from STEP 7 by the count of claims from STEP 4 | N/A |
06/19/2024 | 3.27.0 | MCR-9-019-21 | UPDATE | Focus area | Managed care | N/A |
06/19/2024 | 3.27.0 | MCR-9-018-20 | UPDATE | Threshold minimum | TBD | N/A |
06/19/2024 | 3.27.0 | MCR-9-018-20 | UPDATE | Threshold maximum | TBD | N/A |
06/19/2024 | 3.27.0 | MCR-9-018-20 | UPDATE | Annotation | Calculate the percentage of PHP capitation payments with a non-missing plan id that do not have a corresponding managed care participation PHP plan | N/A |
06/19/2024 | 3.27.0 | MCR-9-018-20 | UPDATE | Specification | STEP 1: Active non-duplicate paid OT claims during report monthDefine 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 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 Capitation Payment: Original, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "2"2. ADJUSTMENT-IND = "0"STEP 3: Type of serviceOf the claims that meet the criteria from STEP 2, further restrict them by the following criteria: 1. TYPE-OF-SERVICE = "122"STEP 4: Non-missing plan idOf the claims that meet the criteria from STEP 3, further restrict them by the following criteria: 1. PLAN-ID-NUMBER is not missingSTEP 5: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 6: Managed care enrollment on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 5, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 7: No managed care participation PHP planOf the claim lines that meet the criteria from STEP 4, further restrict them by attempting to merge them with the data from STEP 6 and keeping those that satisfy the following criteria:1a. PLAN-ID-NUMBER = MANAGED-CARE-PLAN-ID2a. MSIS-IDENTIFICATION-NUM matches 3a. MANAGED-CARE-PLAN-TYPE does NOT equal (“05”, “06”, “07”, “08”, “09”, “10”, “11”, “12”, “13”, “14”, “15”, “16”, “18”, “19”) for any records where 1a and 2a are satisfiedORIt is not the case that:1b. PLAN-ID-NUMBER = MANAGED-CARE-PLAN-ID2b. MSIS-IDENTIFICATION-NUM matches STEP 8: Calculate the percentage for the measureDivide the count of claims from STEP 7 by the count of claims from STEP 4 | N/A |
06/19/2024 | 3.27.0 | MCR-9-018-20 | UPDATE | Focus area | Managed care | N/A |
06/19/2024 | 3.27.0 | MCR-13-019-21 | UPDATE | Threshold minimum | TBD | N/A |
06/19/2024 | 3.27.0 | MCR-13-019-21 | UPDATE | Threshold maximum | TBD | N/A |
06/19/2024 | 3.27.0 | MCR-13-019-21 | UPDATE | Annotation | Calculate the percentage of Comprehensive MCO capitation payments with a non-missing plan ID that do not have a corresponding managed care participation Comprehensive MCO plan | N/A |
06/19/2024 | 3.27.0 | MCR-13-019-21 | UPDATE | Specification | STEP 1: Active non-duplicate paid OT claims during report monthDefine 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 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: S-CHIP Capitation Payment: Original, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "B"2. ADJUSTMENT-IND = "0"STEP 3: Type of serviceOf the claims that meet the criteria from STEP 2, further restrict them by the following criteria: 1. TYPE-OF-SERVICE = "119"STEP 4: Non-missing plan idOf the claims that meet the criteria from STEP 3, further restrict them by the following criteria: 1. PLAN-ID-NUMBER is not missingSTEP 5: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 6: Managed care enrollment on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 5, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 7: No managed care participation Comprehensive MCO planOf the claim lines that meet the criteria from STEP 4, further restrict them by attempting to merge them with the data from STEP 6 and keeping those that satisfy the following criteria:1a. PLAN-ID-NUMBER = MANAGED-CARE-PLAN-ID2a. MSIS-IDENTIFICATION-NUM matches 3a. MANAGED-CARE-PLAN-TYPE does NOT equal “01”, “04”, or “17” for any records where 1a and 2a are satisfiedORIt is not the case that:1b. PLAN-ID-NUMBER = MANAGED-CARE-PLAN-ID2b. MSIS-IDENTIFICATION-NUM matches STEP 8: Calculate the percentage for the measureDivide the count of claims from STEP 7 by the count of claims from STEP 4 | N/A |
06/19/2024 | 3.27.0 | MCR-13-019-21 | UPDATE | Focus area | Managed care | N/A |
06/19/2024 | 3.27.0 | MCR-13-018-20 | UPDATE | Threshold minimum | TBD | N/A |
06/19/2024 | 3.27.0 | MCR-13-018-20 | UPDATE | Threshold maximum | TBD | N/A |
06/19/2024 | 3.27.0 | MCR-13-018-20 | UPDATE | Annotation | Calculate the percentage of PHP capitation payments with a non-missing plan ID that do not have a corresponding managed care participation PHP plan | N/A |
06/19/2024 | 3.27.0 | MCR-13-018-20 | UPDATE | Specification | STEP 1: Active non-duplicate paid OT claims during report monthDefine 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 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: S-CHIP Capitation Payment: Original, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "B"2. ADJUSTMENT-IND = "0"STEP 3: Type of serviceOf the claims that meet the criteria from STEP 2, further restrict them by the following criteria: 1. TYPE-OF-SERVICE = "122"STEP 4: Non-missing plan idOf the claims that meet the criteria from STEP 3, further restrict them by the following criteria: 1. PLAN-ID-NUMBER is not missingSTEP 5: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 6: Managed care enrollment on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 5, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 7: No managed care participation PHP planOf the claim lines that meet the criteria from STEP 4, further restrict them by attempting to merge them with the data from STEP 6 and keeping those that satisfy the following criteria:1a. PLAN-ID-NUMBER = MANAGED-CARE-PLAN-ID2a. MSIS-IDENTIFICATION-NUM matches 3a. MANAGED-CARE-PLAN-TYPE does NOT equal (“05”, “06”, “07”, “08”, “09”, “10”, “11”, “12”, “13”, “14”, “15”, “16”, “18”, “19”) for any records where 1a and 2a are satisfiedORIt is not the case that:1b. PLAN-ID-NUMBER = MANAGED-CARE-PLAN-ID2b. MSIS-IDENTIFICATION-NUM matches STEP 8: Calculate the percentage for the measureDivide the count of claims from STEP 7 by the count of claims from STEP 4 | N/A |
06/19/2024 | 3.27.0 | MCR-13-018-20 | UPDATE | Focus area | Managed care | N/A |
11/15/2023 | 3.16.0 | EXP-11-160_1-163 | UPDATE | Specification | STEP 1: Active non-duplicate paid OT claims during report monthDefine 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 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 FFS: Original, Non-Crossover, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "1"2. ADJUSTMENT-IND = "0" 3. CROSSOVER-INDICATOR = "0" or is missingSTEP 3: Payment at the line levelOf the claims that meet the criteria from STEP 2, count records where:1. PAYMENT-LEVEL-IND = "2"STEP 4: Billed amount $0Of the claims that meet the criteria from STEP 3, count records with1. TOT-BILLED-AMT = "0"STEP 5: Calculate the percentage for the measureDivide the count of claims from STEP 4 by the count of claims from STEP 3 | STEP 1: Active non-duplicate paid OT claims during report monthDefine 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 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 FFS: Original, Non-Crossover, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "1"2. ADJUSTMENT-IND = "0" 3. CROSSOVER-INDICATOR = "0" or is missingSTEP 3: Payment at the line levelOf the claims that meet the criteria from STEP 2, count records where:1. PAYMENT-LEVEL-IND = "2"STEP 4: Billed amount $0Of the claims that meet the criteria from STEP 3, count records with1. BILLED-AMT = "0"STEP 5: Calculate the percentage for the measureDivide the count of claims from STEP 4 by the count of claims from STEP 3 |
02/02/2024 | 3.18.0 | EL-6-037-37 | UPDATE | Specification | STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Variable demographics on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 1, join to segment VARIABLE-DEMOGRAPHIC-ELG00003 by keeping records that satisfy the following criteria:1a. VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE <= last day of the DQ report month2a. VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE >= last day of the DQ report month OR missingOR1b. VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE is missing2b. VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE is missingSTEP 3: U.S. citizen immigration statusOf the MSIS IDs that meet the criteria from STEP 2, further refine the population by keeping MSIS IDs where:1. IMMIGRATION-STATUS = "3"STEP 4: Restricted Benefits Code designationOf the MSIS IDs that meet the criteria from STEP 3, restrict to those where:1. RESTRICTED-BENEFITS-CODE is not “2” or "4"STEP 5: Calculate percentageDivide the count of unique MSIS IDs from STEP 4 by the count of unique MSIS IDs from STEP 3 | STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Variable demographics on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 1, join to segment VARIABLE-DEMOGRAPHIC-ELG00003 by keeping records that satisfy the following criteria:1a. VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE <= last day of the DQ report month2a. VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE >= last day of the DQ report month OR missingOR1b. VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE is missing2b. VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE is missingSTEP 3: U.S. citizen immigration statusOf the MSIS IDs that meet the criteria from STEP 2, further refine the population by keeping MSIS IDs where:1. IMMIGRATION-STATUS = "3"STEP 4: Eligibility determinants on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 3, join to segment ELIGIBILITY-DETERMINANTS-ELG00005 by keeping records that satisfy the following criteria:1. PRIMARY-ELIGIBILITY-GROUP-IND = 12a. ELIGIBILITY-DETERMINANT-EFF-DATE <= last day of the DQ report month3a. ELIGIBILITY-DETERMINANT-END-DATE >= last day of the DQ report month OR missingOR2b. ELIGIBILITY-DETERMINANT-EFF-DATE is missing3b. ELIGIBILITY-DETERMINANT-END-DATE is missing"STEP 5: Restricted Benefits Code designationOf the MSIS IDs that meet the criteria from STEP 4, restrict to those where:1. RESTRICTED-BENEFITS-CODE is not “2” or "4"STEP 6: Calculate percentageDivide the count of unique MSIS IDs from STEP 5 by the count of unique MSIS IDs from STEP 4 |
02/02/2024 | 3.18.0 | EL-1-038-45 | UPDATE | Annotation | N/A | Calculate the percentage of eligibles with English as a primary language |
02/02/2024 | 3.18.0 | EL-1-038-45 | UPDATE | Specification | N/A | STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Variable demographics on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 1, join to segment VARIABLE-DEMOGRAPHIC-ELG00003 by keeping records that satisfy the following criteria:1a. VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE <= last day of the DQ report month2a. VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE >= last day of the DQ report month OR missingOR1b. VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE is missing2b. VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE is missingSTEP 3: Primary language code is not missingOf the MSIS IDs that meet the criteria from STEP 2, restrict to segments where:1. PRIMARY-LANGUAGE-CODE is not missingSTEP 4: Primary language code is EnglishOf the MSIS IDs that meet the criteria from STEP 3, restrict to segments where:1. PRIMARY-LANGUAGE-CODE = "ENG"STEP 5: Calculate percentageDivide the count of unique MSIS IDs from STEP 4 by the count of unique MSIS IDs from STEP 3 |
02/02/2024 | 3.18.0 | PRV-2-011-11 | UPDATE | Specification | STEP 1: Provider enrolled on the last day of DQ report monthDefine the provider population from segment PROV-MEDICAID-ENROLLMENT-PRV00007 by keeping active records that satisfy the following criteria:1. PROV-MEDICAID-EFF-DATE <= last day of the reporting month2. PROV-MEDICAID-END-DATE >= last day of the reporting month OR missing3. SUBMITTING-STATE-PROV-ID is not missingSTEP 2: Provider attributes are active on last day of DQ report monthOf the providers that meet the criteria from STEP 1, further refine the population using segment PROVIDER-ATTRIBUTES-MAIN- PRV00002 by keeping records that satisfy the following criteria:1. PROV-ATTRIBUTES-EFF-DATE <= last day of the reporting month2. PROV-ATTRIBUTES-END-DATE >= last day of the reporting month or missing3. SUBMITTING-STATE-PROV-ID is not missingSTEP 3: Provider Classification Lookup Designation indicates NPI is required (non-atypical providers)Of the SUBMITTING-STATE-PROV-IDs that meet the criteria from STEP 2, further refine the population by keeping records that meet the following criteria:1. PROV-CLASSIFICATION-TYPE and PROVIDER-CLASSIFICATION-CODE match values in Atypical Provider Lookup table2. 'NPI Required' is "YES"STEP 4: NPI is presentOf the records that meet the criteria from STEP 3, restrict to segments that meet the following criteria:1. PROV-IDENTIFIER-TYPE = 22. SUBMITTING-STATE-PROV-ID is not NULLSTEP 5: NPI is not presentSubtract the count of unique SUBMITTING-STATE-PROV-IDs from STEP 4 from the count from STEP 3STEP 6: Calculate percent that do not have an NPIDivide the count of unique SUBMITTING-STATE-PROV-IDs from STEP 5 by the count from STEP 3 | STEP 1: Provider enrolled on the last day of DQ report monthDefine the provider population from segment PROV-MEDICAID-ENROLLMENT-PRV00007 by keeping active records that satisfy the following criteria:1. PROV-MEDICAID-EFF-DATE <= last day of the reporting month2. PROV-MEDICAID-END-DATE >= last day of the reporting month OR missing3. SUBMITTING-STATE-PROV-ID is not missingSTEP 2: Provider taxonomy is active on the last day of DQ report monthOf the providers that meet the criteria from STEP 1, further refine the population using segment PROVIDER-TAXONOMY-CLASSIFICATION-PRV00006 by keeping records that satisfy the following criteria:1a. PROV-TAXONOMY-CLASSIFICATION-EFF-DATE <= last day of the reporting month2a. PROV-TAXONOMY-CLASSIFICATION-END-DATE >= last day of the reporting month OR missingOR1b. PROV-TAXONOMY-CLASSIFICATION-EFF-DATE is missing2b. PROV-TAXONOMY-CLASSIFICATION-END-DATE is missingSTEP 3: Provider Classification Lookup Designation indicates NPI is required (non-atypical providers)Of the SUBMITTING-STATE-PROV-IDs that meet the criteria from STEP 2, further refine the population by keeping records that meet the following criteria:1. PROV-CLASSIFICATION-TYPE and PROVIDER-CLASSIFICATION-CODE match values in Atypical Provider Lookup table2. 'NPI Required' is "YES"STEP 4: Provider identifier is active on the last day of DQ report monthOf the providers that meet the criteria from STEP 3, further refine the population using segment PROV-IDENTIFIER-PRV00005 by keeping records that satisfy the following criteria:1a. PROV-IDENTIFIER-EFF-DATE <= last day of the reporting month2a. PROV-IDENTIFIER-END-DATE >= last day of the reporting month OR missingOR1b. PROV-IDENTIFIER-EFF-DATE is missing2b. PROV-IDENTIFIER-END-DATE is missingSTEP 5: NPI is presentOf the records that meet the criteria from STEP 4, restrict to segments that meet the following criteria:1. PROV-IDENTIFIER-TYPE = 22. SUBMITTING-STATE-PROV-ID is not NULLSTEP 6: NPI is not presentSubtract the count of unique SUBMITTING-STATE-PROV-IDs from STEP 5 from the count from STEP 3STEP 7: Calculate percent that do not have an NPIDivide the count of unique SUBMITTING-STATE-PROV-IDs from STEP 6 by the count from STEP 3 |
06/19/2024 | 3.27.0 | EL-1-037-44 | UPDATE | Focus area | Race/ethnicity | N/A |
06/19/2024 | 3.27.0 | EL-1-036-43 | UPDATE | Focus area | Race/ethnicity | N/A |
06/19/2024 | 3.27.0 | EL-1-035-42 | UPDATE | Focus area | Race/ethnicity | N/A |
06/19/2024 | 3.27.0 | EL-1-034-41 | UPDATE | Focus area | Race/ethnicity | N/A |
06/19/2024 | 3.27.0 | EL-1-033-40 | UPDATE | Focus area | Race/ethnicity | N/A |
06/19/2024 | 3.27.0 | EL-1-032-39 | UPDATE | Focus area | Race/ethnicity | N/A |
11/15/2023 | 3.16.0 | MCR-65-012-12 | UPDATE | Specification | STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Managed care participation on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 1, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 3: Enrollment in Integrated Care for Dual EligiblesOf the MSIS IDs that meet the criteria for STEP 2, further refine the population to MSIS IDs where MANAGED-CARE-PLAN-TYPE = ("80")STEP 4: Active non-duplicate paid OT claims during report monthDefine the OT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 5: Medicaid Capitation Payment: Original, Paid ClaimsOf the claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "B" or "2" STEP 6: Link MSIS IDs from EL to OTRetain the MSIS IDs from STEP 3 that link to an OT claim from STEP 5 using the Plan IDsSTEP 7: Count MSIS IDs without Integrated Care for Dual EligiblesSubtract the number of unique MSIS IDs in STEP 6 from the number of unique MSIS IDs in STEP 3STEP 8: Calculate percentageDivide the count of unique MSIS IDs in STEP 7 by the count of unique MSIS IDs in STEP 3 | STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Managed care participation on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 1, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 3: Enrollment in Integrated Care for Dual EligiblesOf the MSIS IDs that meet the criteria for STEP 2, further refine the population to MSIS IDs where MANAGED-CARE-PLAN-TYPE = ("80")STEP 4: Active non-duplicate paid OT claims during report monthDefine the OT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 5: Medicaid & S-CHIP Capitation Payment: Original and Adjustment, Paid ClaimsOf the claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "B" or "2" STEP 6: Link MSIS IDs from EL to OTRetain the MSIS IDs from STEP 3 that link to an OT claim from STEP 5 using the Plan IDsSTEP 7: Count MSIS IDs without Integrated Care for Dual EligiblesSubtract the number of unique MSIS IDs in STEP 6 from the number of unique MSIS IDs in STEP 3STEP 8: Calculate percentageDivide the count of unique MSIS IDs in STEP 7 by the count of unique MSIS IDs in STEP 3 |
11/15/2023 | 3.16.0 | MCR-65-011-11 | UPDATE | Specification | STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Managed care participation on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 1, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 3: Enrollment in Health/Medical HomeOf the MSIS IDs that meet the criteria for STEP 2, further refine the population to MSIS IDs where MANAGED-CARE-PLAN-TYPE = ("70")STEP 4: Active non-duplicate paid OT claims during report monthDefine the OT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 5: Medicaid Capitation Payment: Original, Paid ClaimsOf the claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "B" or "2" STEP 6: Link MSIS IDs from EL to OTRetain the MSIS IDs from STEP 3 that link to an OT claim from STEP 5 using the Plan IDsSTEP 7: Count MSIS IDs without Health/Medical HomeSubtract the number of unique MSIS IDs in STEP 6 from the number of unique MSIS IDs in STEP 3STEP 8: Calculate percentageDivide the count of unique MSIS IDs in STEP 7 by the count of unique MSIS IDs in STEP 3 | STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Managed care participation on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 1, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 3: Enrollment in Health/Medical HomeOf the MSIS IDs that meet the criteria for STEP 2, further refine the population to MSIS IDs where MANAGED-CARE-PLAN-TYPE = ("70")STEP 4: Active non-duplicate paid OT claims during report monthDefine the OT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 5: Medicaid & S-CHIP Capitation Payment: Original and Adjustment, Paid ClaimsOf the claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "B" or "2" STEP 6: Link MSIS IDs from EL to OTRetain the MSIS IDs from STEP 3 that link to an OT claim from STEP 5 using the Plan IDsSTEP 7: Count MSIS IDs without Health/Medical HomeSubtract the number of unique MSIS IDs in STEP 6 from the number of unique MSIS IDs in STEP 3STEP 8: Calculate percentageDivide the count of unique MSIS IDs in STEP 7 by the count of unique MSIS IDs in STEP 3 |
11/15/2023 | 3.16.0 | MCR-65-010-10 | UPDATE | Specification | STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Managed care participation on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 1, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 3: Enrollment in ACOOf the MSIS IDs that meet the criteria for STEP 2, further refine the population to MSIS IDs where MANAGED-CARE-PLAN-TYPE = ("60")STEP 4: Active non-duplicate paid OT claims during report monthDefine the OT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 5: Medicaid Capitation Payment: Original, Paid ClaimsOf the claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "B" or "2" STEP 6: Link MSIS IDs from EL to OTRetain the MSIS IDs from STEP 3 that link to an OT claim from STEP 5 using the Plan IDsSTEP 7: Count MSIS IDs without ACOSubtract the number of unique MSIS IDs in STEP 6 from the number of unique MSIS IDs in STEP 3STEP 8: Calculate percentageDivide the count of unique MSIS IDs in STEP 7 by the count of unique MSIS IDs in STEP 3 | STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Managed care participation on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 1, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 3: Enrollment in ACOOf the MSIS IDs that meet the criteria for STEP 2, further refine the population to MSIS IDs where MANAGED-CARE-PLAN-TYPE = ("60")STEP 4: Active non-duplicate paid OT claims during report monthDefine the OT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 5: Medicaid & S-CHIP Capitation Payment: Original and Adjustment, Paid ClaimsOf the claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "B" or "2" STEP 6: Link MSIS IDs from EL to OTRetain the MSIS IDs from STEP 3 that link to an OT claim from STEP 5 using the Plan IDsSTEP 7: Count MSIS IDs without ACOSubtract the number of unique MSIS IDs in STEP 6 from the number of unique MSIS IDs in STEP 3STEP 8: Calculate percentageDivide the count of unique MSIS IDs in STEP 7 by the count of unique MSIS IDs in STEP 3 |
11/15/2023 | 3.16.0 | MCR-65-009-9 | UPDATE | Specification | STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Managed care participation on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 1, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 3: Enrollment in Disease ManagementOf the MSIS IDs that meet the criteria for STEP 2, further refine the population to MSIS IDs where MANAGED-CARE-PLAN-TYPE = ("02", "03", or "16")STEP 4: Active non-duplicate paid OT claims during report monthDefine the OT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 5: Medicaid Capitation Payment: Original, Paid ClaimsOf the claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "B" or "2" STEP 6: Link MSIS IDs from EL to OTRetain the MSIS IDs from STEP 3 that link to an OT claim from STEP 5 using the Plan IDsSTEP 7: Count MSIS IDs without Disease ManagementSubtract the number of unique MSIS IDs in STEP 6 from the number of unique MSIS IDs in STEP 3STEP 8: Calculate percentageDivide the count of unique MSIS IDs in STEP 7 by the count of unique MSIS IDs in STEP 3 | STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Managed care participation on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 1, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 3: Enrollment in Disease ManagementOf the MSIS IDs that meet the criteria for STEP 2, further refine the population to MSIS IDs where MANAGED-CARE-PLAN-TYPE = ("02", "03", or "16")STEP 4: Active non-duplicate paid OT claims during report monthDefine the OT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 5: Medicaid & S-CHIP Capitation Payment: Original and Adjustment, Paid ClaimsOf the claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "B" or "2" STEP 6: Link MSIS IDs from EL to OTRetain the MSIS IDs from STEP 3 that link to an OT claim from STEP 5 using the Plan IDsSTEP 7: Count MSIS IDs without Disease ManagementSubtract the number of unique MSIS IDs in STEP 6 from the number of unique MSIS IDs in STEP 3STEP 8: Calculate percentageDivide the count of unique MSIS IDs in STEP 7 by the count of unique MSIS IDs in STEP 3 |
11/15/2023 | 3.16.0 | MCR-65-008-8 | UPDATE | Specification | STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Managed care participation on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 1, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 3: Enrollment in LTSSOf the MSIS IDs that meet the criteria for STEP 2, further refine the population to MSIS IDs where MANAGED-CARE-PLAN-TYPE = ("07" or "19")STEP 4: Active non-duplicate paid OT claims during report monthDefine the OT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 5: Medicaid Capitation Payment: Original, Paid ClaimsOf the claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "B" or "2" STEP 6: Link MSIS IDs from EL to OTRetain the MSIS IDs from STEP 3 that link to an OT claim from STEP 5 using the Plan IDsSTEP 7: Count MSIS IDs without LTSSSubtract the number of unique MSIS IDs in STEP 6 from the number of unique MSIS IDs in STEP 3STEP 8: Calculate percentageDivide the count of unique MSIS IDs in STEP 7 by the count of unique MSIS IDs in STEP 3 | STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Managed care participation on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 1, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 3: Enrollment in LTSSOf the MSIS IDs that meet the criteria for STEP 2, further refine the population to MSIS IDs where MANAGED-CARE-PLAN-TYPE = ("07" or "19")STEP 4: Active non-duplicate paid OT claims during report monthDefine the OT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 5: Medicaid & S-CHIP Capitation Payment: Original and Adjustment, Paid ClaimsOf the claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "B" or "2" STEP 6: Link MSIS IDs from EL to OTRetain the MSIS IDs from STEP 3 that link to an OT claim from STEP 5 using the Plan IDsSTEP 7: Count MSIS IDs without LTSSSubtract the number of unique MSIS IDs in STEP 6 from the number of unique MSIS IDs in STEP 3STEP 8: Calculate percentageDivide the count of unique MSIS IDs in STEP 7 by the count of unique MSIS IDs in STEP 3 |
11/15/2023 | 3.16.0 | MCR-65-007-7 | UPDATE | Specification | STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Managed care participation on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 1, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 3: Enrollment in Mental Health PAHPOf the MSIS IDs that meet the criteria for STEP 2, further refine the population to MSIS IDs where MANAGED-CARE-PLAN-TYPE = ("09", "11", or "13")STEP 4: Active non-duplicate paid OT claims during report monthDefine the OT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 5: Medicaid Capitation Payment: Original, Paid ClaimsOf the claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "B" or "2" STEP 6: Link MSIS IDs from EL to OTRetain the MSIS IDs from STEP 3 that link to an OT claim from STEP 5 using the Plan IDsSTEP 7: Count MSIS IDs without Mental Health PAHPSubtract the number of unique MSIS IDs in STEP 6 from the number of unique MSIS IDs in STEP 3STEP 8: Calculate percentageDivide the count of unique MSIS IDs in STEP 7 by the count of unique MSIS IDs in STEP 3 | STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Managed care participation on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 1, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 3: Enrollment in Mental Health PAHPOf the MSIS IDs that meet the criteria for STEP 2, further refine the population to MSIS IDs where MANAGED-CARE-PLAN-TYPE = ("09", "11", or "13")STEP 4: Active non-duplicate paid OT claims during report monthDefine the OT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 5: Medicaid & S-CHIP Capitation Payment: Original and Adjustment, Paid ClaimsOf the claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "B" or "2" STEP 6: Link MSIS IDs from EL to OTRetain the MSIS IDs from STEP 3 that link to an OT claim from STEP 5 using the Plan IDsSTEP 7: Count MSIS IDs without Mental Health PAHPSubtract the number of unique MSIS IDs in STEP 6 from the number of unique MSIS IDs in STEP 3STEP 8: Calculate percentageDivide the count of unique MSIS IDs in STEP 7 by the count of unique MSIS IDs in STEP 3 |
11/15/2023 | 3.16.0 | MCR-65-006-6 | UPDATE | Specification | STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Managed care participation on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 1, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 3: Enrollment in Mental Health PIHPOf the MSIS IDs that meet the criteria for STEP 2, further refine the population to MSIS IDs where MANAGED-CARE-PLAN-TYPE = ("08", "10", or "12")STEP 4: Active non-duplicate paid OT claims during report monthDefine the OT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 5: Medicaid Capitation Payment: Original, Paid ClaimsOf the claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "B" or "2" STEP 6: Link MSIS IDs from EL to OTRetain the MSIS IDs from STEP 3 that link to an OT claim from STEP 5 using the Plan IDsSTEP 7: Count MSIS IDs without Mental Health PIHPSubtract the number of unique MSIS IDs in STEP 6 from the number of unique MSIS IDs in STEP 3STEP 8: Calculate percentageDivide the count of unique MSIS IDs in STEP 7 by the count of unique MSIS IDs in STEP 3 | STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Managed care participation on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 1, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 3: Enrollment in Mental Health PIHPOf the MSIS IDs that meet the criteria for STEP 2, further refine the population to MSIS IDs where MANAGED-CARE-PLAN-TYPE = ("08", "10", or "12")STEP 4: Active non-duplicate paid OT claims during report monthDefine the OT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 5: Medicaid & S-CHIP Capitation Payment: Original and Adjustment, Paid ClaimsOf the claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "B" or "2" STEP 6: Link MSIS IDs from EL to OTRetain the MSIS IDs from STEP 3 that link to an OT claim from STEP 5 using the Plan IDsSTEP 7: Count MSIS IDs without Mental Health PIHPSubtract the number of unique MSIS IDs in STEP 6 from the number of unique MSIS IDs in STEP 3STEP 8: Calculate percentageDivide the count of unique MSIS IDs in STEP 7 by the count of unique MSIS IDs in STEP 3 |
11/15/2023 | 3.16.0 | MCR-65-005-5 | UPDATE | Specification | STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Managed care participation on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 1, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 3: Enrollment in Pharmacy PAHPOf the MSIS IDs that meet the criteria for STEP 2, further refine the population to MSIS IDs where MANAGED-CARE-PLAN-TYPE = ("18")STEP 4: Active non-duplicate paid OT claims during report monthDefine the OT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 5: Medicaid Capitation Payment: Original, Paid ClaimsOf the claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "B" or "2" STEP 6: Link MSIS IDs from EL to OTRetain the MSIS IDs from STEP 3 that link to an OT claim from STEP 5 using the Plan IDsSTEP 7: Count MSIS IDs without Pharmacy PAHPSubtract the number of unique MSIS IDs in STEP 6 from the number of unique MSIS IDs in STEP 3STEP 8: Calculate percentageDivide the count of unique MSIS IDs in STEP 7 by the count of unique MSIS IDs in STEP 3 | STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Managed care participation on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 1, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 3: Enrollment in Pharmacy PAHPOf the MSIS IDs that meet the criteria for STEP 2, further refine the population to MSIS IDs where MANAGED-CARE-PLAN-TYPE = ("18")STEP 4: Active non-duplicate paid OT claims during report monthDefine the OT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 5: Medicaid & S-CHIP Capitation Payment: Original and Adjustment, Paid ClaimsOf the claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "B" or "2" STEP 6: Link MSIS IDs from EL to OTRetain the MSIS IDs from STEP 3 that link to an OT claim from STEP 5 using the Plan IDsSTEP 7: Count MSIS IDs without Pharmacy PAHPSubtract the number of unique MSIS IDs in STEP 6 from the number of unique MSIS IDs in STEP 3STEP 8: Calculate percentageDivide the count of unique MSIS IDs in STEP 7 by the count of unique MSIS IDs in STEP 3 |
11/15/2023 | 3.16.0 | MCR-65-004-4 | UPDATE | Specification | STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Managed care participation on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 1, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 3: Enrollment in Dental PAHPOf the MSIS IDs that meet the criteria for STEP 2, further refine the population to MSIS IDs where MANAGED-CARE-PLAN-TYPE = ("14")STEP 4: Active non-duplicate paid OT claims during report monthDefine the OT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 5: Medicaid Capitation Payment: Original, Paid ClaimsOf the claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "B" or "2" STEP 6: Link MSIS IDs from EL to OTRetain the MSIS IDs from STEP 3 that link to an OT claim from STEP 5 using the Plan IDsSTEP 7: Count MSIS IDs without Dental PAHPSubtract the number of unique MSIS IDs in STEP 6 from the number of unique MSIS IDs in STEP 3STEP 8: Calculate percentageDivide the count of unique MSIS IDs in STEP 7 by the count of unique MSIS IDs in STEP 3 | STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Managed care participation on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 1, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 3: Enrollment in Dental PAHPOf the MSIS IDs that meet the criteria for STEP 2, further refine the population to MSIS IDs where MANAGED-CARE-PLAN-TYPE = ("14")STEP 4: Active non-duplicate paid OT claims during report monthDefine the OT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 5: Medicaid & S-CHIP Capitation Payment: Original and Adjustment, Paid ClaimsOf the claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "B" or "2" STEP 6: Link MSIS IDs from EL to OTRetain the MSIS IDs from STEP 3 that link to an OT claim from STEP 5 using the Plan IDsSTEP 7: Count MSIS IDs without Dental PAHPSubtract the number of unique MSIS IDs in STEP 6 from the number of unique MSIS IDs in STEP 3STEP 8: Calculate percentageDivide the count of unique MSIS IDs in STEP 7 by the count of unique MSIS IDs in STEP 3 |
11/15/2023 | 3.16.0 | MCR-65-003-3 | UPDATE | Specification | STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Managed care participation on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 1, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 3: Enrollment in Transportation PAHPOf the MSIS IDs that meet the criteria for STEP 2, further refine the population to MSIS IDs where MANAGED-CARE-PLAN-TYPE = ("15")STEP 4: Active non-duplicate paid OT claims during report monthDefine the OT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 5: Medicaid Capitation Payment: Original, Paid ClaimsOf the claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "B" or "2" STEP 6: Link MSIS IDs from EL to OTRetain the MSIS IDs from STEP 3 that link to an OT claim from STEP 5 using the Plan IDsSTEP 7: Count MSIS IDs without Transportation PAHPSubtract the number of unique MSIS IDs in STEP 6 from the number of unique MSIS IDs in STEP 3STEP 8: Calculate percentageDivide the count of unique MSIS IDs in STEP 7 by the count of unique MSIS IDs in STEP 3 | STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Managed care participation on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 1, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 3: Enrollment in Transportation PAHPOf the MSIS IDs that meet the criteria for STEP 2, further refine the population to MSIS IDs where MANAGED-CARE-PLAN-TYPE = ("15")STEP 4: Active non-duplicate paid OT claims during report monthDefine the OT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 5: Medicaid & S-CHIP Capitation Payment: Original and Adjustment, Paid ClaimsOf the claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "B" or "2" STEP 6: Link MSIS IDs from EL to OTRetain the MSIS IDs from STEP 3 that link to an OT claim from STEP 5 using the Plan IDsSTEP 7: Count MSIS IDs without Transportation PAHPSubtract the number of unique MSIS IDs in STEP 6 from the number of unique MSIS IDs in STEP 3STEP 8: Calculate percentageDivide the count of unique MSIS IDs in STEP 7 by the count of unique MSIS IDs in STEP 3 |
11/15/2023 | 3.16.0 | MCR-65-002-2 | UPDATE | Specification | STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Managed care participation on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 1, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 3: Enrollment in PACE planOf the MSIS IDs that meet the criteria for STEP 2, further refine the population to MSIS IDs where MANAGED-CARE-PLAN-TYPE = ("17")STEP 4: Active non-duplicate paid OT claims during report monthDefine the OT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 5: Medicaid Capitation Payment: Original, Paid ClaimsOf the claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "B" or "2" STEP 6: Link MSIS IDs from EL to OTRetain the MSIS IDs from STEP 3 that link to an OT claim from STEP 5 using the Plan IDSTEP 7: Count MSIS IDs without PACE planSubtract the number of unique MSIS IDs in STEP 6 from the number of unique MSIS IDs in STEP 3STEP 8: Calculate percentageDivide the count of unique MSIS IDs in STEP 7 by the count of unique MSIS IDs in STEP 3 | STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Managed care participation on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 1, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 3: Enrollment in PACE planOf the MSIS IDs that meet the criteria for STEP 2, further refine the population to MSIS IDs where MANAGED-CARE-PLAN-TYPE = ("17")STEP 4: Active non-duplicate paid OT claims during report monthDefine the OT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 5: Medicaid & S-CHIP Capitation Payment: Original and Adjustment, Paid ClaimsOf the claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "B" or "2" STEP 6: Link MSIS IDs from EL to OTRetain the MSIS IDs from STEP 3 that link to an OT claim from STEP 5 using the Plan IDSTEP 7: Count MSIS IDs without PACE planSubtract the number of unique MSIS IDs in STEP 6 from the number of unique MSIS IDs in STEP 3STEP 8: Calculate percentageDivide the count of unique MSIS IDs in STEP 7 by the count of unique MSIS IDs in STEP 3 |
11/15/2023 | 3.16.0 | MCR-65-001-1 | UPDATE | Specification | STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Managed care participation on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 1, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 3: Enrollment in Comprehensive MCOOf the MSIS IDs that meet the criteria for STEP 2, further refine the population to MSIS IDs where MANAGED-CARE-PLAN-TYPE = ("01" or "04")STEP 4: Active non-duplicate paid OT claims during report monthDefine the OT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 5: Medicaid Capitation Payment: Original, Paid ClaimsOf the claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "B" or "2" STEP 6: Link MSIS IDs from EL to OTRetain the MSIS IDs from STEP 3 that link to an OT claim from STEP 5 using the Plan IDSTEP 7: Count MSIS IDs without Comprehensive MCOSubtract the number of unique MSIS IDs in STEP 6 from the number of unique MSIS IDs in STEP 3STEP 8: Calculate percentageDivide the count of unique MSIS IDs in STEP 7 by the count of unique MSIS IDs in STEP 3 | STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Managed care participation on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 1, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 3: Enrollment in Comprehensive MCOOf the MSIS IDs that meet the criteria for STEP 2, further refine the population to MSIS IDs where MANAGED-CARE-PLAN-TYPE = ("01" or "04")STEP 4: Active non-duplicate paid OT claims during report monthDefine the OT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 5: Medicaid & S-CHIP Capitation Payment: Original and Adjustment, Paid ClaimsOf the claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "B" or "2" STEP 6: Link MSIS IDs from EL to OTRetain the MSIS IDs from STEP 3 that link to an OT claim from STEP 5 using the Plan IDSTEP 7: Count MSIS IDs without Comprehensive MCOSubtract the number of unique MSIS IDs in STEP 6 from the number of unique MSIS IDs in STEP 3STEP 8: Calculate percentageDivide the count of unique MSIS IDs in STEP 7 by the count of unique MSIS IDs in STEP 3 |
06/19/2024 | 3.27.0 | EL-1-031-38 | UPDATE | Priority | N/A | High |
06/19/2024 | 3.27.0 | EL-1-031-38 | UPDATE | Category | N/A | Beneficiary demographics |
06/19/2024 | 3.27.0 | EL-1-031-38 | UPDATE | For ta comprehensive | No | TA- Inferential |
06/19/2024 | 3.27.0 | EL-1-031-38 | UPDATE | For ta inferential | No | Yes |
06/19/2024 | 3.27.0 | EL-1-031-38 | UPDATE | Ta min | 0 | |
06/19/2024 | 3.27.0 | EL-1-031-38 | UPDATE | Ta max | 0.2 | |
06/19/2024 | 3.27.0 | EL-1-031-38 | UPDATE | Threshold minimum | TBD | 0 |
06/19/2024 | 3.27.0 | EL-1-031-38 | UPDATE | Threshold maximum | TBD | 0.2 |
06/19/2024 | 3.27.0 | EL-1-030-37 | UPDATE | Measure name | % of MSIS IDs that have a Native Hawaiian or Other Pacific Islander race (RACE = 012, 013, 014, 015, 016) | % of MSIS IDs that have Native Hawaiian or Other Pacific Islander race (RACE = 012, 013, 014, 015, 016) |
06/19/2024 | 3.27.0 | EL-1-030-37 | UPDATE | Threshold minimum | TBD | N/A |
06/19/2024 | 3.27.0 | EL-1-030-37 | UPDATE | Threshold maximum | TBD | N/A |
06/19/2024 | 3.27.0 | EL-1-030-37 | UPDATE | Annotation | Calculate the percentage of MSIS IDs with a RACE value of "012", "013", "014", "015", or "016" | N/A |
06/19/2024 | 3.27.0 | EL-1-030-37 | UPDATE | Specification | STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Race information on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 1, join to segment RACE-INFORMATION-ELG00016 by keeping active records that satisfy the following criteria:1a. RACE-DECLARATION-EFF-DATE <= last day of the DQ report month2a. RACE-DECLARATION-END-DATE >= last day of the DQ report month OR missingOR1b. RACE-DECLARATION-EFF-DATE is missing2b. RACE-DECLARATION-END-DATE is missingSTEP 3: Race is Native Hawaiian or Other Pacific IslanderOf the MSIS IDs that meet the criteria from STEP 2, further restrict them by the following criteria:1. RACE = (“012,” “013,” “014,” “015,” or “016,”) on any record segmentSTEP 4: PercentageDivide the count from STEP 3 by the count in STEP 1*Note: This can include MSIS IDs from STEP 1 that did not join to a race information segment. | N/A |
06/19/2024 | 3.27.0 | EL-1-030-37 | UPDATE | Focus area | Race/ethnicity | N/A |
06/19/2024 | 3.27.0 | EL-1-029-36 | UPDATE | Measure name | % of MSIS IDs that have an Asian race (RACE = 004, 005, 006, 007, 008, 009, 010, 011) | % of MSIS IDs that have Asian race (RACE = 004, 005, 006, 007, 008, 009, 010, 011) |
06/19/2024 | 3.27.0 | EL-1-029-36 | UPDATE | Threshold minimum | TBD | N/A |
06/19/2024 | 3.27.0 | EL-1-029-36 | UPDATE | Threshold maximum | TBD | N/A |
06/19/2024 | 3.27.0 | EL-1-029-36 | UPDATE | Annotation | Calculate the percentage of MSIS IDs with a RACE value of "004", "005", "006", "007", '008", "009", "010", or "011" | N/A |
06/19/2024 | 3.27.0 | EL-1-029-36 | UPDATE | Specification | STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Race information on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 1, join to segment RACE-INFORMATION-ELG00016 by keeping active records that satisfy the following criteria:1a. RACE-DECLARATION-EFF-DATE <= last day of the DQ report month2a. RACE-DECLARATION-END-DATE >= last day of the DQ report month OR missingOR1b. RACE-DECLARATION-EFF-DATE is missing2b. RACE-DECLARATION-END-DATE is missingSTEP 3: Race is AsianOf the MSIS IDs that meet the criteria from STEP 2, further restrict them by the following criteria:1. RACE = (“004,” “005,” “006,” “007,” “008,” “009,” “010,” or “011,”) on any record segmentSTEP 4: PercentageDivide the count from STEP 3 by the count in STEP 1*Note: This can include MSIS IDs from STEP 1 that did not join to a race information segment. | N/A |
06/19/2024 | 3.27.0 | EL-1-029-36 | UPDATE | Focus area | Race/ethnicity | N/A |
06/19/2024 | 3.27.0 | EL-1-028-35 | UPDATE | Measure name | % of MSIS IDs that have an American Indian or Alaska Native race (RACE = 003) | % of MSIS IDs that have American Indian or Alaska Native race (RACE = 003) |
06/19/2024 | 3.27.0 | EL-1-028-35 | UPDATE | Threshold minimum | TBD | N/A |
06/19/2024 | 3.27.0 | EL-1-028-35 | UPDATE | Threshold maximum | TBD | N/A |
06/19/2024 | 3.27.0 | EL-1-028-35 | UPDATE | Annotation | Calculate the percentage of MSIS IDs with a RACE value of "003" | N/A |
06/19/2024 | 3.27.0 | EL-1-028-35 | UPDATE | Specification | STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Race information on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 1, join to segment RACE-INFORMATION-ELG00016 by keeping active records that satisfy the following criteria:1a. RACE-DECLARATION-EFF-DATE <= last day of the DQ report month2a. RACE-DECLARATION-END-DATE >= last day of the DQ report month OR missingOR1b. RACE-DECLARATION-EFF-DATE is missing2b. RACE-DECLARATION-END-DATE is missingSTEP 3: Race is American Indian or Alaska NativeOf the MSIS IDs that meet the criteria from STEP 2, further restrict them by the following criteria:1. RACE equals "003" on any record segmentSTEP 4: PercentageDivide the count from STEP 3 by the count in STEP 1*Note: This can include MSIS IDs from STEP 1 that did not join to a race information segment. | N/A |
06/19/2024 | 3.27.0 | EL-1-028-35 | UPDATE | Focus area | Race/ethnicity | N/A |
06/19/2024 | 3.27.0 | EL-1-027-34 | UPDATE | Measure name | % of MSIS IDs that have a Black or African American race (RACE = 002) | % of MSIS IDs that have Black or African American race (RACE = 002) |
06/19/2024 | 3.27.0 | EL-1-027-34 | UPDATE | Priority | N/A | High |
06/19/2024 | 3.27.0 | EL-1-027-34 | UPDATE | Category | N/A | Beneficiary demographics |
06/19/2024 | 3.27.0 | EL-1-027-34 | UPDATE | For ta comprehensive | No | TA- Inferential |
06/19/2024 | 3.27.0 | EL-1-027-34 | UPDATE | For ta inferential | No | Yes |
06/19/2024 | 3.27.0 | EL-1-027-34 | UPDATE | Ta min | 0.01 | |
06/19/2024 | 3.27.0 | EL-1-027-34 | UPDATE | Ta max | 0.9 | |
06/19/2024 | 3.27.0 | EL-1-027-34 | UPDATE | Threshold minimum | TBD | 0.01 |
06/19/2024 | 3.27.0 | EL-1-027-34 | UPDATE | Threshold maximum | TBD | 0.9 |
06/19/2024 | 3.27.0 | EL-1-026-33 | UPDATE | Measure name | % of MSIS IDs that have a White race (RACE = 001) | % of MSIS IDs that have White race (RACE = 001) |
06/19/2024 | 3.27.0 | EL-1-026-33 | UPDATE | Priority | N/A | High |
06/19/2024 | 3.27.0 | EL-1-026-33 | UPDATE | Category | N/A | Beneficiary demographics |
06/19/2024 | 3.27.0 | EL-1-026-33 | UPDATE | For ta comprehensive | No | TA- Inferential |
06/19/2024 | 3.27.0 | EL-1-026-33 | UPDATE | For ta inferential | No | Yes |
06/19/2024 | 3.27.0 | EL-1-026-33 | UPDATE | Ta min | 0.01 | |
06/19/2024 | 3.27.0 | EL-1-026-33 | UPDATE | Ta max | 0.9 | |
06/19/2024 | 3.27.0 | EL-1-026-33 | UPDATE | Threshold minimum | TBD | 0.01 |
06/19/2024 | 3.27.0 | EL-1-026-33 | UPDATE | Threshold maximum | TBD | 0.9 |
02/02/2024 | 3.18.0 | EL-3-019_1-34 | UPDATE | Focus area | N/A | Unwinding |
03/27/2024 | 3.22.0 | EL-1-025-31 | UPDATE | Priority | High | N/A |
03/27/2024 | 3.22.0 | EL-1-025-31 | UPDATE | Category | Beneficiary demographics | N/A |
03/27/2024 | 3.22.0 | EL-1-025-31 | UPDATE | For ta comprehensive | TA- Inferential | No |
03/27/2024 | 3.22.0 | EL-1-025-31 | UPDATE | For ta inferential | Yes | No |
03/27/2024 | 3.22.0 | EL-1-025-31 | UPDATE | Ta min | 0 | |
03/27/2024 | 3.22.0 | EL-1-025-31 | UPDATE | Ta max | 0.001 | |
03/27/2024 | 3.22.0 | EL-1-025-31 | UPDATE | Annotation | Calculate the percentage of eligibles where any address county code or zip code is not in address state and is not missing | N/A |
03/27/2024 | 3.22.0 | EL-1-025-31 | UPDATE | Specification | STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Eligible contact on the last day of the DQ report monthUsing the MSIS IDs that meet the criteria from STEP 1, join to segment ELIGIBLE-CONTACT-INFORMATION-ELG00004 by keeping records that satisfy the following criteria:1a. ELIGIBLE-ADDR-EFF-DATE<= last day of the DQ report month2a. ELIGIBLE-ADDR-END-DATE >= last day of the DQ report month OR missingOR1b. ELIGIBLE-ADDR-EFF-DATE is missing2b. ELIGIBLE-ADDR-END-DATE is missingSTEP 3: Eligible county code or zip code does not align with eligible state and is not missingOf the records that meet the criteria from STEP 2, restrict to segments where:1a. ELIGIBILE-COUNTY-CODE is not missing2a. ELIGIBLE-COUNTY-CODE is not in ELIGIBLE-STATE OR2a. ELIGIBLE-ZIP-CODE is not missing2b. ELIGIBLE-ZIP-CODE is not in ELIGIBLE-STATESTEP 4: Calculate percentageDivide the count of unique MSIS IDs from STEP 3 by the count of unique MSIS IDs from STEP 2 | N/A |
02/02/2024 | 3.18.0 | MIS-86-020-20 | UPDATE | Priority | High | N/A |
02/02/2024 | 3.18.0 | MIS-86-020-20 | UPDATE | Category | Utilization | N/A |
02/02/2024 | 3.18.0 | MIS-86-020-20 | UPDATE | For ta comprehensive | TA- Inferential | No |
02/02/2024 | 3.18.0 | MIS-86-020-20 | UPDATE | For ta inferential | Yes | No |
02/02/2024 | 3.18.0 | MIS-86-020-20 | UPDATE | Ta min | 0 | |
02/02/2024 | 3.18.0 | MIS-86-020-20 | UPDATE | Ta max | 0.02 | |
11/15/2023 | 3.16.0 | MIS-86-017-17 | UPDATE | Measure name | % missing: OT-RX-CLAIM-QUANTITY-ACTUAL (CRX00003) | % missing: PRESCRIPTION-QUANTITY-ACTUAL (CRX00003) |
11/15/2023 | 3.16.0 | MIS-86-006-6 | UPDATE | Measure name | % missing: DISPENSE-FEE (CRX00003) | % missing: DISPENSE-FEE-SUBMITTED (CRX00003) |
11/15/2023 | 3.16.0 | MIS-86-004-4 | UPDATE | Measure name | % missing: COPAY-AMT (CRX00003) | % missing: BENEFICIARY-COPAYMENT-PAID-AMOUNT (CRX00003) |
06/19/2024 | 3.27.0 | MIS-85-027-27 | UPDATE | Threshold minimum | TBD | N/A |
06/19/2024 | 3.27.0 | MIS-85-027-27 | UPDATE | Threshold maximum | TBD | N/A |
11/15/2023 | 3.16.0 | MIS-85-023-23 | UPDATE | Priority | Critical | N/A |
11/15/2023 | 3.16.0 | MIS-85-023-23 | UPDATE | Category | File integrity | N/A |
11/15/2023 | 3.16.0 | MIS-85-023-23 | UPDATE | For ta comprehensive | TA- Inferential | No |
11/15/2023 | 3.16.0 | MIS-85-023-23 | UPDATE | For ta inferential | Yes | No |
11/15/2023 | 3.16.0 | MIS-85-023-23 | UPDATE | Ta min | 0 | |
11/15/2023 | 3.16.0 | MIS-85-023-23 | UPDATE | Ta max | 0.02 | |
11/15/2023 | 3.16.0 | MIS-85-023-23 | UPDATE | Annotation | Numeric | N/A |
11/15/2023 | 3.16.0 | MIS-85-023-23 | UPDATE | Specification | STEP 1: Active non-duplicate RX claims during DQ report monthDefine the RX claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 2: Medicaid or S-CHIP Encounter: Original and Replacement, 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. ADJUSTMENT-IND = "0" or "4"STEP 3: Exclude sub-capitation encounters (For measures MIS-85-014-14, MIS-85-025-25, and MIS-85-026-26 ONLY) Of the claims that meet the criteria from STEP 2, further restrict them by the following criteria:1. SOURCE-LOCATION is NOT equal to "22" or "23"STEP 4: Missing data elementOf the claims that meet the criteria from STEP 2 (or STEP 3 for selected measures), select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 5: Calculate percentageDivide the count of claims from STEP 4 by the count of claims from STEP 2 (or STEP 3 for selected measures) | N/A |
02/02/2024 | 3.18.0 | MIS-85-014-14 | UPDATE | Priority | High | N/A |
02/02/2024 | 3.18.0 | MIS-85-014-14 | UPDATE | Category | Expenditures | N/A |
02/02/2024 | 3.18.0 | MIS-85-014-14 | UPDATE | For ta comprehensive | TA- Inferential | No |
02/02/2024 | 3.18.0 | MIS-85-014-14 | UPDATE | For ta inferential | Yes | No |
02/02/2024 | 3.18.0 | MIS-85-014-14 | UPDATE | Ta min | 0 | |
02/02/2024 | 3.18.0 | MIS-85-014-14 | UPDATE | Ta max | 0.02 | |
02/02/2024 | 3.18.0 | MIS-85-014-14 | UPDATE | Focus area | Managed care | N/A |
06/19/2024 | 3.27.0 | MIS-85-005-5 | UPDATE | Priority | High | N/A |
06/19/2024 | 3.27.0 | MIS-85-005-5 | UPDATE | Category | Provider information | N/A |
06/19/2024 | 3.27.0 | MIS-85-005-5 | UPDATE | For ta comprehensive | TA- Inferential | No |
06/19/2024 | 3.27.0 | MIS-85-005-5 | UPDATE | For ta inferential | Yes | No |
06/19/2024 | 3.27.0 | MIS-85-005-5 | UPDATE | Ta min | 0 | |
06/19/2024 | 3.27.0 | MIS-85-005-5 | UPDATE | Ta max | 0.02 | |
06/19/2024 | 3.27.0 | MIS-85-005-5 | UPDATE | Annotation | Character | N/A |
06/19/2024 | 3.27.0 | MIS-85-005-5 | UPDATE | Specification | STEP 1: Active non-duplicate RX claims during DQ report monthDefine the RX claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 2: Medicaid or S-CHIP Encounter: Original and Replacement, 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. ADJUSTMENT-IND = "0" or "4"STEP 3: Exclude sub-capitation encounters (For measures MIS-85-014-14, MIS-85-025-25, and MIS-85-026-26 ONLY) Of the claims that meet the criteria from STEP 2, further restrict them by the following criteria:1. SOURCE-LOCATION is NOT equal to "22" or "23"STEP 4: Missing data elementOf the claims that meet the criteria from STEP 2 (or STEP 3 for selected measures), select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 5: Calculate percentageDivide the count of claims from STEP 4 by the count of claims from STEP 2 (or STEP 3 for selected measures) | N/A |
06/19/2024 | 3.27.0 | MIS-85-005-5 | UPDATE | Focus area | Managed care | N/A |
06/19/2024 | 3.27.0 | MIS-85-004-4 | UPDATE | Priority | High | N/A |
06/19/2024 | 3.27.0 | MIS-85-004-4 | UPDATE | Category | Provider information | N/A |
06/19/2024 | 3.27.0 | MIS-85-004-4 | UPDATE | For ta comprehensive | TA- Inferential | No |
06/19/2024 | 3.27.0 | MIS-85-004-4 | UPDATE | For ta inferential | Yes | No |
06/19/2024 | 3.27.0 | MIS-85-004-4 | UPDATE | Ta min | 0 | |
06/19/2024 | 3.27.0 | MIS-85-004-4 | UPDATE | Ta max | 0.02 | |
06/19/2024 | 3.27.0 | MIS-85-004-4 | UPDATE | Annotation | Character | N/A |
06/19/2024 | 3.27.0 | MIS-85-004-4 | UPDATE | Specification | STEP 1: Active non-duplicate RX claims during DQ report monthDefine the RX claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 2: Medicaid or S-CHIP Encounter: Original and Replacement, 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. ADJUSTMENT-IND = "0" or "4"STEP 3: Exclude sub-capitation encounters (For measures MIS-85-014-14, MIS-85-025-25, and MIS-85-026-26 ONLY) Of the claims that meet the criteria from STEP 2, further restrict them by the following criteria:1. SOURCE-LOCATION is NOT equal to "22" or "23"STEP 4: Missing data elementOf the claims that meet the criteria from STEP 2 (or STEP 3 for selected measures), select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 5: Calculate percentageDivide the count of claims from STEP 4 by the count of claims from STEP 2 (or STEP 3 for selected measures) | N/A |
06/19/2024 | 3.27.0 | MIS-85-004-4 | UPDATE | Focus area | Managed care | N/A |
11/15/2023 | 3.16.0 | MIS-85-003-3 | UPDATE | Measure name | % missing: BENEFICIARY-DEDUCTIBLE-AMOUNT (CRX00002) | % missing: TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT (CRX00002) |
11/15/2023 | 3.16.0 | MIS-85-002-2 | UPDATE | Measure name | % missing: BENEFICIARY-COPAYMENT-AMOUNT (CRX00002) | % missing: TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT (CRX00002) |
11/15/2023 | 3.16.0 | MIS-85-001-1 | UPDATE | Measure name | % missing: BENEFICIARY-COINSURANCE-AMOUNT (CRX00002) | % missing: TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT (CRX00002) |
02/02/2024 | 3.18.0 | MIS-84-030-30 | UPDATE | Priority | High | N/A |
02/02/2024 | 3.18.0 | MIS-84-030-30 | UPDATE | Category | Utilization | N/A |
02/02/2024 | 3.18.0 | MIS-84-030-30 | UPDATE | For ta comprehensive | TA- Inferential | No |
02/02/2024 | 3.18.0 | MIS-84-030-30 | UPDATE | For ta inferential | Yes | No |
02/02/2024 | 3.18.0 | MIS-84-030-30 | UPDATE | Ta min | 0 | |
02/02/2024 | 3.18.0 | MIS-84-030-30 | UPDATE | Ta max | 0.02 | |
11/15/2023 | 3.16.0 | MIS-84-019-19 | UPDATE | Measure name | % missing: OT-RX-CLAIM-QUANTITY-ACTUAL (COT00003) | % missing: SERVICE-QUANTITY-ACTUAL (COT00003) |
06/19/2024 | 3.27.0 | MIS-84-009-9 | UPDATE | Threshold minimum | TBD | N/A |
06/19/2024 | 3.27.0 | MIS-84-009-9 | UPDATE | Threshold maximum | TBD | N/A |
11/15/2023 | 3.16.0 | MIS-84-006-6 | UPDATE | Priority | High | N/A |
11/15/2023 | 3.16.0 | MIS-84-006-6 | UPDATE | Category | Utilization | N/A |
11/15/2023 | 3.16.0 | MIS-84-006-6 | UPDATE | For ta comprehensive | TA- Inferential | No |
11/15/2023 | 3.16.0 | MIS-84-006-6 | UPDATE | For ta inferential | Yes | No |
11/15/2023 | 3.16.0 | MIS-84-006-6 | UPDATE | Ta min | 0 | |
11/15/2023 | 3.16.0 | MIS-84-006-6 | UPDATE | Ta max | 0.02 | |
11/15/2023 | 3.16.0 | MIS-84-006-6 | UPDATE | Annotation | Numeric | N/A |
11/15/2023 | 3.16.0 | MIS-84-006-6 | UPDATE | Specification | STEP 1: Active non-duplicate OT claims during DQ report monthDefine the OT claims universe at the header level by importing both headers and lines that satisfy the following criteria:For Headers:1. Reporting Period from 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 or S-CHIP Encounter: Original and Replacement, 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. ADJUSTMENT-IND = "0" or "4"STEP 3: Exclude sub-capitation encounters (For measure MIS-84-004-4 ONLY) Of the claims that meet the criteria from STEP 2, further restrict them by the following criteria:1. SOURCE-LOCATION is NOT equal to "22" or "23"STEP 4: Missing data elementOf the claims that meet the criteria from STEP 2 (or STEP 3 for selected measure), select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 5: Calculate percentageDivide the count of claim lines from STEP 4 by the count of claim lines from STEP 2 (or STEP 3 for selected measure) | N/A |
11/15/2023 | 3.16.0 | MIS-84-005-5 | UPDATE | Measure name | % missing: COPAY-AMT (COT00003) | % missing: BENEFICIARY-COPAYMENT-PAID-AMOUNT (COT00003) |
11/15/2023 | 3.16.0 | MIS-84-002-2 | UPDATE | Priority | High | N/A |
11/15/2023 | 3.16.0 | MIS-84-002-2 | UPDATE | Category | Utilization | N/A |
11/15/2023 | 3.16.0 | MIS-84-002-2 | UPDATE | For ta comprehensive | TA- Inferential | No |
11/15/2023 | 3.16.0 | MIS-84-002-2 | UPDATE | For ta inferential | Yes | No |
11/15/2023 | 3.16.0 | MIS-84-002-2 | UPDATE | Ta min | 0 | |
11/15/2023 | 3.16.0 | MIS-84-002-2 | UPDATE | Ta max | 0 | |
11/15/2023 | 3.16.0 | MIS-84-002-2 | UPDATE | Threshold maximum | 0 | 0.02 |
11/15/2023 | 3.16.0 | MIS-84-002-2 | UPDATE | Annotation | Numeric | N/A |
11/15/2023 | 3.16.0 | MIS-84-002-2 | UPDATE | Specification | STEP 1: Active non-duplicate OT claims during DQ report monthDefine the OT claims universe at the header level by importing both headers and lines that satisfy the following criteria:For Headers:1. Reporting Period from 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 or S-CHIP Encounter: Original and Replacement, 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. ADJUSTMENT-IND = "0" or "4"STEP 3: Exclude sub-capitation encounters (For measure MIS-84-004-4 ONLY) Of the claims that meet the criteria from STEP 2, further restrict them by the following criteria:1. SOURCE-LOCATION is NOT equal to "22" or "23"STEP 4: Missing data elementOf the claims that meet the criteria from STEP 2 (or STEP 3 for selected measure), select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 5: Calculate percentageDivide the count of claim lines from STEP 4 by the count of claim lines from STEP 2 (or STEP 3 for selected measure) | N/A |
02/02/2024 | 3.18.0 | MIS-83-020-20 | UPDATE | Priority | High | N/A |
02/02/2024 | 3.18.0 | MIS-83-020-20 | UPDATE | Category | Expenditures | N/A |
02/02/2024 | 3.18.0 | MIS-83-020-20 | UPDATE | For ta comprehensive | TA- Inferential | No |
02/02/2024 | 3.18.0 | MIS-83-020-20 | UPDATE | For ta inferential | Yes | No |
02/02/2024 | 3.18.0 | MIS-83-020-20 | UPDATE | Ta min | 0 | |
02/02/2024 | 3.18.0 | MIS-83-020-20 | UPDATE | Ta max | 0.02 | |
02/02/2024 | 3.18.0 | MIS-83-020-20 | UPDATE | Focus area | Managed care | N/A |
11/15/2023 | 3.16.0 | MIS-83-016-16 | UPDATE | Priority | Critical | N/A |
11/15/2023 | 3.16.0 | MIS-83-016-16 | UPDATE | Category | File integrity | N/A |
11/15/2023 | 3.16.0 | MIS-83-016-16 | UPDATE | For ta comprehensive | TA- Inferential | No |
11/15/2023 | 3.16.0 | MIS-83-016-16 | UPDATE | For ta inferential | Yes | No |
11/15/2023 | 3.16.0 | MIS-83-016-16 | UPDATE | Ta min | 0 | |
11/15/2023 | 3.16.0 | MIS-83-016-16 | UPDATE | Ta max | 0.02 | |
11/15/2023 | 3.16.0 | MIS-83-016-16 | UPDATE | Annotation | Numeric | N/A |
11/15/2023 | 3.16.0 | MIS-83-016-16 | UPDATE | Specification | STEP 1: Active non-duplicate OT claims during DQ report monthDefine the OT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 2: Medicaid or S-CHIP Encounter: Original and Replacement, 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. ADJUSTMENT-IND = "0" or "4"STEP 3: Exclude sub-capitation encounters (For measures MIS-83-020-20, MIS-83-028-28, and MIS-83-029-29 ONLY) Of the claims that meet the criteria from STEP 2, further restrict them by the following criteria:1. SOURCE-LOCATION is NOT equal to "22" or "23"STEP 4: Missing data elementOf the claims that meet the criteria from STEP 2 (or STEP 3 for selected measures), select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 5: Calculate percentageDivide the count of claims from STEP 4 by the count of claims from STEP 2 (or STEP 3 for selected measures) | N/A |
06/19/2024 | 3.27.0 | MIS-83-007-7 | UPDATE | Priority | High | N/A |
06/19/2024 | 3.27.0 | MIS-83-007-7 | UPDATE | Category | Provider information | N/A |
06/19/2024 | 3.27.0 | MIS-83-007-7 | UPDATE | For ta comprehensive | TA- Inferential | No |
06/19/2024 | 3.27.0 | MIS-83-007-7 | UPDATE | For ta inferential | Yes | No |
06/19/2024 | 3.27.0 | MIS-83-007-7 | UPDATE | Ta min | 0 | |
06/19/2024 | 3.27.0 | MIS-83-007-7 | UPDATE | Ta max | 0.02 | |
06/19/2024 | 3.27.0 | MIS-83-007-7 | UPDATE | Annotation | Character | N/A |
06/19/2024 | 3.27.0 | MIS-83-007-7 | UPDATE | Specification | STEP 1: Active non-duplicate OT claims during DQ report monthDefine the OT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 2: Medicaid or S-CHIP Encounter: Original and Replacement, 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. ADJUSTMENT-IND = "0" or "4"STEP 3: Exclude sub-capitation encounters (For measures MIS-83-020-20, MIS-83-028-28, and MIS-83-029-29 ONLY) Of the claims that meet the criteria from STEP 2, further restrict them by the following criteria:1. SOURCE-LOCATION is NOT equal to "22" or "23"STEP 4: Missing data elementOf the claims that meet the criteria from STEP 2 (or STEP 3 for selected measures), select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 5: Calculate percentageDivide the count of claims from STEP 4 by the count of claims from STEP 2 (or STEP 3 for selected measures) | N/A |
06/19/2024 | 3.27.0 | MIS-83-007-7 | UPDATE | Focus area | Managed care | N/A |
06/19/2024 | 3.27.0 | MIS-83-005-5 | UPDATE | Priority | High | Medium |
06/19/2024 | 3.27.0 | MIS-83-005-5 | UPDATE | Ta max | 0.15 | 0.3 |
06/19/2024 | 3.27.0 | MIS-83-005-5 | UPDATE | Threshold maximum | 0.15 | 0.3 |
11/15/2023 | 3.16.0 | MIS-83-004-4 | UPDATE | Measure name | % missing: BENEFICIARY-DEDUCTIBLE-AMOUNT (COT00002) | % missing: TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT (COT00002) |
11/15/2023 | 3.16.0 | MIS-83-003-3 | UPDATE | Measure name | % missing: BENEFICIARY-COPAYMENT-AMOUNT (COT00002) | % missing: TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT (COT00002) |
11/15/2023 | 3.16.0 | MIS-83-002-2 | UPDATE | Measure name | % missing: BENEFICIARY-COINSURANCE-AMOUNT (COT00002) | % missing: TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT (COT00002) |
11/15/2023 | 3.16.0 | MIS-83-001-1 | UPDATE | Priority | Critical | N/A |
11/15/2023 | 3.16.0 | MIS-83-001-1 | UPDATE | Category | File integrity | N/A |
11/15/2023 | 3.16.0 | MIS-83-001-1 | UPDATE | For ta comprehensive | TA- Inferential | No |
11/15/2023 | 3.16.0 | MIS-83-001-1 | UPDATE | For ta inferential | Yes | No |
11/15/2023 | 3.16.0 | MIS-83-001-1 | UPDATE | Ta min | 0 | |
11/15/2023 | 3.16.0 | MIS-83-001-1 | UPDATE | Ta max | 0.02 | |
11/15/2023 | 3.16.0 | MIS-83-001-1 | UPDATE | Annotation | Numeric | N/A |
11/15/2023 | 3.16.0 | MIS-83-001-1 | UPDATE | Specification | STEP 1: Active non-duplicate OT claims during DQ report monthDefine the OT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 2: Medicaid or S-CHIP Encounter: Original and Replacement, 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. ADJUSTMENT-IND = "0" or "4"STEP 3: Exclude sub-capitation encounters (For measures MIS-83-020-20, MIS-83-028-28, and MIS-83-029-29 ONLY) Of the claims that meet the criteria from STEP 2, further restrict them by the following criteria:1. SOURCE-LOCATION is NOT equal to "22" or "23"STEP 4: Missing data elementOf the claims that meet the criteria from STEP 2 (or STEP 3 for selected measures), select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 5: Calculate percentageDivide the count of claims from STEP 4 by the count of claims from STEP 2 (or STEP 3 for selected measures) | N/A |
02/02/2024 | 3.18.0 | MIS-82-017-17 | UPDATE | Priority | High | N/A |
02/02/2024 | 3.18.0 | MIS-82-017-17 | UPDATE | Category | Utilization | N/A |
02/02/2024 | 3.18.0 | MIS-82-017-17 | UPDATE | For ta comprehensive | TA- Inferential | No |
02/02/2024 | 3.18.0 | MIS-82-017-17 | UPDATE | For ta inferential | Yes | No |
02/02/2024 | 3.18.0 | MIS-82-017-17 | UPDATE | Ta min | 0 | |
02/02/2024 | 3.18.0 | MIS-82-017-17 | UPDATE | Ta max | 0.02 | |
11/15/2023 | 3.16.0 | MIS-82-003-3 | UPDATE | Priority | High | N/A |
11/15/2023 | 3.16.0 | MIS-82-003-3 | UPDATE | Category | Utilization | N/A |
11/15/2023 | 3.16.0 | MIS-82-003-3 | UPDATE | For ta comprehensive | TA- Inferential | No |
11/15/2023 | 3.16.0 | MIS-82-003-3 | UPDATE | For ta inferential | Yes | No |
11/15/2023 | 3.16.0 | MIS-82-003-3 | UPDATE | Ta min | 0 | |
11/15/2023 | 3.16.0 | MIS-82-003-3 | UPDATE | Ta max | 0.02 | |
11/15/2023 | 3.16.0 | MIS-82-003-3 | UPDATE | Annotation | Numeric | N/A |
11/15/2023 | 3.16.0 | MIS-82-003-3 | UPDATE | Specification | STEP 1: Active non-duplicate LT claims during DQ report monthDefine the LT claims universe at the header level by importing both headers and lines that satisfy the following criteria:For Headers:1. Reporting Period from 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 or S-CHIP Encounter: Original and Replacement, 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. ADJUSTMENT-IND = "0" or "4"STEP 3: Exclude sub-capitation encounters (For measure MIS-82-011-11 ONLY) Of the claims that meet the criteria from STEP 2, further restrict them by the following criteria:1. SOURCE-LOCATION is NOT equal to "22" or "23"STEP 4: Missing data elementOf the claims that meet the criteria from STEP 2 (or STEP 3 for selected measure), select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 5: Calculate percentageDivide the count of claim lines from STEP 4 by the count of claim lines from STEP 2 (or STEP 3 for selected measure) | N/A |
11/15/2023 | 3.16.0 | MIS-82-002-2 | UPDATE | Priority | High | N/A |
11/15/2023 | 3.16.0 | MIS-82-002-2 | UPDATE | Category | Utilization | N/A |
11/15/2023 | 3.16.0 | MIS-82-002-2 | UPDATE | For ta comprehensive | TA- Inferential | No |
11/15/2023 | 3.16.0 | MIS-82-002-2 | UPDATE | For ta inferential | Yes | No |
11/15/2023 | 3.16.0 | MIS-82-002-2 | UPDATE | Ta min | 0 | |
11/15/2023 | 3.16.0 | MIS-82-002-2 | UPDATE | Ta max | 0 | |
11/15/2023 | 3.16.0 | MIS-82-002-2 | UPDATE | Threshold maximum | 0 | 0.02 |
11/15/2023 | 3.16.0 | MIS-82-002-2 | UPDATE | Annotation | Numeric | N/A |
11/15/2023 | 3.16.0 | MIS-82-002-2 | UPDATE | Specification | STEP 1: Active non-duplicate LT claims during DQ report monthDefine the LT claims universe at the header level by importing both headers and lines that satisfy the following criteria:For Headers:1. Reporting Period from 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 or S-CHIP Encounter: Original and Replacement, 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. ADJUSTMENT-IND = "0" or "4"STEP 3: Exclude sub-capitation encounters (For measure MIS-82-011-11 ONLY) Of the claims that meet the criteria from STEP 2, further restrict them by the following criteria:1. SOURCE-LOCATION is NOT equal to "22" or "23"STEP 4: Missing data elementOf the claims that meet the criteria from STEP 2 (or STEP 3 for selected measure), select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 5: Calculate percentageDivide the count of claim lines from STEP 4 by the count of claim lines from STEP 2 (or STEP 3 for selected measure) | N/A |
02/02/2024 | 3.18.0 | MIS-81-026-26 | UPDATE | Priority | High | N/A |
02/02/2024 | 3.18.0 | MIS-81-026-26 | UPDATE | Category | Expenditures | N/A |
02/02/2024 | 3.18.0 | MIS-81-026-26 | UPDATE | For ta comprehensive | TA- Inferential | No |
02/02/2024 | 3.18.0 | MIS-81-026-26 | UPDATE | For ta inferential | Yes | No |
02/02/2024 | 3.18.0 | MIS-81-026-26 | UPDATE | Ta min | 0 | |
02/02/2024 | 3.18.0 | MIS-81-026-26 | UPDATE | Ta max | 0.02 | |
02/02/2024 | 3.18.0 | MIS-81-026-26 | UPDATE | Focus area | Managed care | N/A |
11/15/2023 | 3.16.0 | MIS-81-018-18 | UPDATE | Priority | Critical | N/A |
11/15/2023 | 3.16.0 | MIS-81-018-18 | UPDATE | Category | File integrity | N/A |
11/15/2023 | 3.16.0 | MIS-81-018-18 | UPDATE | For ta comprehensive | TA- Inferential | No |
11/15/2023 | 3.16.0 | MIS-81-018-18 | UPDATE | For ta inferential | Yes | No |
11/15/2023 | 3.16.0 | MIS-81-018-18 | UPDATE | Ta min | 0 | |
11/15/2023 | 3.16.0 | MIS-81-018-18 | UPDATE | Ta max | 0.02 | |
11/15/2023 | 3.16.0 | MIS-81-018-18 | UPDATE | Annotation | Numeric | N/A |
11/15/2023 | 3.16.0 | MIS-81-018-18 | UPDATE | Specification | STEP 1: Active non-duplicate LT claims during DQ report monthDefine the LT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 2: Medicaid or S-CHIP Encounter: Original and Replacement, 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. ADJUSTMENT-IND = "0" or "4"STEP 3: Exclude sub-capitation encounters (For measures MIS-81-026-26, MIS-81-040-40, and MIS-81-041-41 ONLY) Of the claims that meet the criteria from STEP 2, further restrict them by the following criteria:1. SOURCE-LOCATION is NOT equal to "22" or "23"STEP 4: Missing data elementOf the claims that meet the criteria from STEP 2 (or STEP 3 for selected measures), select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 4: Calculate percentageDivide the count of claims from STEP 4 by the count of claims from STEP 2 (or STEP 3 for selected measures), | N/A |
06/19/2024 | 3.27.0 | MIS-81-009-9 | UPDATE | Priority | High | N/A |
06/19/2024 | 3.27.0 | MIS-81-009-9 | UPDATE | Category | Provider information | N/A |
06/19/2024 | 3.27.0 | MIS-81-009-9 | UPDATE | For ta comprehensive | TA- Inferential | No |
06/19/2024 | 3.27.0 | MIS-81-009-9 | UPDATE | For ta inferential | Yes | No |
06/19/2024 | 3.27.0 | MIS-81-009-9 | UPDATE | Ta min | 0 | |
06/19/2024 | 3.27.0 | MIS-81-009-9 | UPDATE | Ta max | 0.02 | |
06/19/2024 | 3.27.0 | MIS-81-009-9 | UPDATE | Annotation | Character | N/A |
06/19/2024 | 3.27.0 | MIS-81-009-9 | UPDATE | Specification | STEP 1: Active non-duplicate LT claims during DQ report monthDefine the LT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 2: Medicaid or S-CHIP Encounter: Original and Replacement, 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. ADJUSTMENT-IND = "0" or "4"STEP 3: Exclude sub-capitation encounters (For measures MIS-81-026-26, MIS-81-040-40, and MIS-81-041-41 ONLY) Of the claims that meet the criteria from STEP 2, further restrict them by the following criteria:1. SOURCE-LOCATION is NOT equal to "22" or "23"STEP 4: Missing data elementOf the claims that meet the criteria from STEP 2 (or STEP 3 for selected measures), select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 4: Calculate percentageDivide the count of claims from STEP 4 by the count of claims from STEP 2 (or STEP 3 for selected measures), | N/A |
06/19/2024 | 3.27.0 | MIS-81-009-9 | UPDATE | Focus area | Managed care | N/A |
06/19/2024 | 3.27.0 | MIS-81-007-7 | UPDATE | Priority | High | N/A |
06/19/2024 | 3.27.0 | MIS-81-007-7 | UPDATE | Category | Provider information | N/A |
06/19/2024 | 3.27.0 | MIS-81-007-7 | UPDATE | For ta comprehensive | TA- Inferential | No |
06/19/2024 | 3.27.0 | MIS-81-007-7 | UPDATE | For ta inferential | Yes | No |
06/19/2024 | 3.27.0 | MIS-81-007-7 | UPDATE | Ta min | 0 | |
06/19/2024 | 3.27.0 | MIS-81-007-7 | UPDATE | Ta max | 0.02 | |
06/19/2024 | 3.27.0 | MIS-81-007-7 | UPDATE | Annotation | Character | N/A |
06/19/2024 | 3.27.0 | MIS-81-007-7 | UPDATE | Specification | STEP 1: Active non-duplicate LT claims during DQ report monthDefine the LT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 2: Medicaid or S-CHIP Encounter: Original and Replacement, 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. ADJUSTMENT-IND = "0" or "4"STEP 3: Exclude sub-capitation encounters (For measures MIS-81-026-26, MIS-81-040-40, and MIS-81-041-41 ONLY) Of the claims that meet the criteria from STEP 2, further restrict them by the following criteria:1. SOURCE-LOCATION is NOT equal to "22" or "23"STEP 4: Missing data elementOf the claims that meet the criteria from STEP 2 (or STEP 3 for selected measures), select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 4: Calculate percentageDivide the count of claims from STEP 4 by the count of claims from STEP 2 (or STEP 3 for selected measures), | N/A |
06/19/2024 | 3.27.0 | MIS-81-007-7 | UPDATE | Focus area | Managed care | N/A |
11/15/2023 | 3.16.0 | MIS-81-006-6 | UPDATE | Measure name | % missing: BENEFICIARY-DEDUCTIBLE-AMOUNT (CLT00002) | % missing: TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT (CLT00002) |
11/15/2023 | 3.16.0 | MIS-81-005-5 | UPDATE | Measure name | % missing: BENEFICIARY-COPAYMENT-AMOUNT (CLT00002) | % missing: TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT (CLT00002) |
11/15/2023 | 3.16.0 | MIS-81-004-4 | UPDATE | Measure name | % missing: BENEFICIARY-COINSURANCE-AMOUNT (CLT00002) | % missing: TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT (CLT00002) |
11/15/2023 | 3.16.0 | MIS-81-003-3 | UPDATE | Priority | Critical | N/A |
11/15/2023 | 3.16.0 | MIS-81-003-3 | UPDATE | Category | File integrity | N/A |
11/15/2023 | 3.16.0 | MIS-81-003-3 | UPDATE | For ta comprehensive | TA- Inferential | No |
11/15/2023 | 3.16.0 | MIS-81-003-3 | UPDATE | For ta inferential | Yes | No |
11/15/2023 | 3.16.0 | MIS-81-003-3 | UPDATE | Ta min | 0 | |
11/15/2023 | 3.16.0 | MIS-81-003-3 | UPDATE | Ta max | 0.02 | |
11/15/2023 | 3.16.0 | MIS-81-003-3 | UPDATE | Annotation | Numeric | N/A |
11/15/2023 | 3.16.0 | MIS-81-003-3 | UPDATE | Specification | STEP 1: Active non-duplicate LT claims during DQ report monthDefine the LT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 2: Medicaid or S-CHIP Encounter: Original and Replacement, 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. ADJUSTMENT-IND = "0" or "4"STEP 3: Exclude sub-capitation encounters (For measures MIS-81-026-26, MIS-81-040-40, and MIS-81-041-41 ONLY) Of the claims that meet the criteria from STEP 2, further restrict them by the following criteria:1. SOURCE-LOCATION is NOT equal to "22" or "23"STEP 4: Missing data elementOf the claims that meet the criteria from STEP 2 (or STEP 3 for selected measures), select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 4: Calculate percentageDivide the count of claims from STEP 4 by the count of claims from STEP 2 (or STEP 3 for selected measures), | N/A |
02/02/2024 | 3.18.0 | MIS-80-017-17 | UPDATE | Priority | High | N/A |
02/02/2024 | 3.18.0 | MIS-80-017-17 | UPDATE | Category | Utilization | N/A |
02/02/2024 | 3.18.0 | MIS-80-017-17 | UPDATE | For ta comprehensive | TA- Inferential | No |
02/02/2024 | 3.18.0 | MIS-80-017-17 | UPDATE | For ta inferential | Yes | No |
02/02/2024 | 3.18.0 | MIS-80-017-17 | UPDATE | Ta min | 0 | |
02/02/2024 | 3.18.0 | MIS-80-017-17 | UPDATE | Ta max | 0.02 | |
11/15/2023 | 3.16.0 | MIS-80-003-3 | UPDATE | Priority | Critical | N/A |
11/15/2023 | 3.16.0 | MIS-80-003-3 | UPDATE | Category | File integrity | N/A |
11/15/2023 | 3.16.0 | MIS-80-003-3 | UPDATE | For ta comprehensive | TA- Inferential | No |
11/15/2023 | 3.16.0 | MIS-80-003-3 | UPDATE | For ta inferential | Yes | No |
11/15/2023 | 3.16.0 | MIS-80-003-3 | UPDATE | Ta min | 0 | |
11/15/2023 | 3.16.0 | MIS-80-003-3 | UPDATE | Ta max | 0.02 | |
11/15/2023 | 3.16.0 | MIS-80-003-3 | UPDATE | Annotation | Numeric | N/A |
11/15/2023 | 3.16.0 | MIS-80-003-3 | UPDATE | Specification | STEP 1: Active non-duplicate IP claims during DQ report monthDefine the IP claims universe at the header level by importing both headers and lines that satisfy the following criteria:For Headers:1. Reporting Period from 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 or S-CHIP Encounter: Original and Replacement, 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. ADJUSTMENT-IND = "0" or "4"STEP 3: Exclude sub-capitation encounters (For measure MIS-80-011-11 ONLY) Of the claims that meet the criteria from STEP 2, further restrict them by the following criteria:1. SOURCE-LOCATION is NOT equal to "22" or "23"STEP 4: Missing data elementOf the claims that meet the criteria from STEP 2 (or STEP 3 for selected measure), select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 5: Calculate percentageDivide the count of claim lines from STEP 4 by the count of claim lines from STEP 2 (or STEP 3 for selected measure). | N/A |
11/15/2023 | 3.16.0 | MIS-80-002-2 | UPDATE | Priority | Critical | N/A |
11/15/2023 | 3.16.0 | MIS-80-002-2 | UPDATE | Category | File integrity | N/A |
11/15/2023 | 3.16.0 | MIS-80-002-2 | UPDATE | For ta comprehensive | TA- Inferential | No |
11/15/2023 | 3.16.0 | MIS-80-002-2 | UPDATE | For ta inferential | Yes | No |
11/15/2023 | 3.16.0 | MIS-80-002-2 | UPDATE | Ta min | 0 | |
11/15/2023 | 3.16.0 | MIS-80-002-2 | UPDATE | Ta max | 0.02 | |
11/15/2023 | 3.16.0 | MIS-80-002-2 | UPDATE | Annotation | Numeric | N/A |
11/15/2023 | 3.16.0 | MIS-80-002-2 | UPDATE | Specification | STEP 1: Active non-duplicate IP claims during DQ report monthDefine the IP claims universe at the header level by importing both headers and lines that satisfy the following criteria:For Headers:1. Reporting Period from 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 or S-CHIP Encounter: Original and Replacement, 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. ADJUSTMENT-IND = "0" or "4"STEP 3: Exclude sub-capitation encounters (For measure MIS-80-011-11 ONLY) Of the claims that meet the criteria from STEP 2, further restrict them by the following criteria:1. SOURCE-LOCATION is NOT equal to "22" or "23"STEP 4: Missing data elementOf the claims that meet the criteria from STEP 2 (or STEP 3 for selected measure), select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 5: Calculate percentageDivide the count of claim lines from STEP 4 by the count of claim lines from STEP 2 (or STEP 3 for selected measure). | N/A |
06/19/2024 | 3.27.0 | MIS-79-055-55 | UPDATE | Threshold minimum | TBD | N/A |
06/19/2024 | 3.27.0 | MIS-79-055-55 | UPDATE | Threshold maximum | TBD | N/A |
02/02/2024 | 3.18.0 | MIS-79-033-33 | UPDATE | Priority | High | N/A |
02/02/2024 | 3.18.0 | MIS-79-033-33 | UPDATE | Category | Expenditures | N/A |
02/02/2024 | 3.18.0 | MIS-79-033-33 | UPDATE | For ta comprehensive | TA- Inferential | No |
02/02/2024 | 3.18.0 | MIS-79-033-33 | UPDATE | For ta inferential | Yes | No |
02/02/2024 | 3.18.0 | MIS-79-033-33 | UPDATE | Ta min | 0 | |
02/02/2024 | 3.18.0 | MIS-79-033-33 | UPDATE | Ta max | 0.02 | |
02/02/2024 | 3.18.0 | MIS-79-033-33 | UPDATE | Focus area | Managed care | N/A |
06/19/2024 | 3.27.0 | MIS-79-010-10 | UPDATE | Priority | High | N/A |
06/19/2024 | 3.27.0 | MIS-79-010-10 | UPDATE | Category | Provider information | N/A |
06/19/2024 | 3.27.0 | MIS-79-010-10 | UPDATE | For ta comprehensive | TA- Inferential | No |
06/19/2024 | 3.27.0 | MIS-79-010-10 | UPDATE | For ta inferential | Yes | No |
06/19/2024 | 3.27.0 | MIS-79-010-10 | UPDATE | Ta min | 0 | |
06/19/2024 | 3.27.0 | MIS-79-010-10 | UPDATE | Ta max | 0.02 | |
06/19/2024 | 3.27.0 | MIS-79-010-10 | UPDATE | Annotation | Character | N/A |
06/19/2024 | 3.27.0 | MIS-79-010-10 | UPDATE | Specification | STEP 1: Active non-duplicate IP claims during DQ report monthDefine the IP claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 2: Medicaid or S-CHIP Encounter: Original and Replacement, 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. ADJUSTMENT-IND = "0" or "4"STEP 3: Exclude sub-capitation encounters (For measures MIS-79-033-33, MIS-79-053-53, and MIS-79-054-54 ONLY) Of the claims that meet the criteria from STEP 2, further restrict them by the following criteria:1. SOURCE-LOCATION is NOT equal to "22" or "23"STEP 4: Missing data elementOf the claims that meet the criteria from STEP 2 (or STEP 3 for selected measures), select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 5: Calculate percentageDivide the count of claims from STEP 4 by the count of claims from STEP 2 (or STEP 3 for selected measures) | N/A |
06/19/2024 | 3.27.0 | MIS-79-010-10 | UPDATE | Focus area | Managed care | N/A |
06/19/2024 | 3.27.0 | MIS-79-008-8 | UPDATE | Priority | High | N/A |
06/19/2024 | 3.27.0 | MIS-79-008-8 | UPDATE | Category | Provider information | N/A |
06/19/2024 | 3.27.0 | MIS-79-008-8 | UPDATE | For ta comprehensive | TA- Inferential | No |
06/19/2024 | 3.27.0 | MIS-79-008-8 | UPDATE | For ta inferential | Yes | No |
06/19/2024 | 3.27.0 | MIS-79-008-8 | UPDATE | Ta min | 0 | |
06/19/2024 | 3.27.0 | MIS-79-008-8 | UPDATE | Ta max | 0.02 | |
06/19/2024 | 3.27.0 | MIS-79-008-8 | UPDATE | Annotation | Character | N/A |
06/19/2024 | 3.27.0 | MIS-79-008-8 | UPDATE | Specification | STEP 1: Active non-duplicate IP claims during DQ report monthDefine the IP claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 2: Medicaid or S-CHIP Encounter: Original and Replacement, 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. ADJUSTMENT-IND = "0" or "4"STEP 3: Exclude sub-capitation encounters (For measures MIS-79-033-33, MIS-79-053-53, and MIS-79-054-54 ONLY) Of the claims that meet the criteria from STEP 2, further restrict them by the following criteria:1. SOURCE-LOCATION is NOT equal to "22" or "23"STEP 4: Missing data elementOf the claims that meet the criteria from STEP 2 (or STEP 3 for selected measures), select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 5: Calculate percentageDivide the count of claims from STEP 4 by the count of claims from STEP 2 (or STEP 3 for selected measures) | N/A |
06/19/2024 | 3.27.0 | MIS-79-008-8 | UPDATE | Focus area | Managed care | N/A |
11/15/2023 | 3.16.0 | MIS-79-007-7 | UPDATE | Measure name | % missing: BENEFICIARY-DEDUCTIBLE-AMOUNT (CIP00002) | % missing: TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT (CIP00002) |
11/15/2023 | 3.16.0 | MIS-79-006-6 | UPDATE | Measure name | % missing: BENEFICIARY-COPAYMENT-AMOUNT (CIP00002) | % missing: TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT (CIP00002) |
11/15/2023 | 3.16.0 | MIS-79-005-5 | UPDATE | Measure name | % missing: BENEFICIARY-COINSURANCE-AMOUNT (CIP00002) | % missing: TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT (CIP00002) |
11/15/2023 | 3.16.0 | MIS-79-001-1 | UPDATE | Priority | High | N/A |
11/15/2023 | 3.16.0 | MIS-79-001-1 | UPDATE | Category | Utilization | N/A |
11/15/2023 | 3.16.0 | MIS-79-001-1 | UPDATE | For ta comprehensive | TA- Inferential | No |
11/15/2023 | 3.16.0 | MIS-79-001-1 | UPDATE | For ta inferential | Yes | No |
11/15/2023 | 3.16.0 | MIS-79-001-1 | UPDATE | Ta min | 0 | |
11/15/2023 | 3.16.0 | MIS-79-001-1 | UPDATE | Ta max | 0.02 | |
11/15/2023 | 3.16.0 | MIS-79-001-1 | UPDATE | Annotation | Numeric | N/A |
11/15/2023 | 3.16.0 | MIS-79-001-1 | UPDATE | Specification | STEP 1: Active non-duplicate IP claims during DQ report monthDefine the IP claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 2: Medicaid or S-CHIP Encounter: Original and Replacement, 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. ADJUSTMENT-IND = "0" or "4"STEP 3: Exclude sub-capitation encounters (For measures MIS-79-033-33, MIS-79-053-53, and MIS-79-054-54 ONLY) Of the claims that meet the criteria from STEP 2, further restrict them by the following criteria:1. SOURCE-LOCATION is NOT equal to "22" or "23"STEP 4: Missing data elementOf the claims that meet the criteria from STEP 2 (or STEP 3 for selected measures), select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 5: Calculate percentageDivide the count of claims from STEP 4 by the count of claims from STEP 2 (or STEP 3 for selected measures) | N/A |
02/02/2024 | 3.18.0 | MIS-28-021-21 | UPDATE | Priority | High | N/A |
02/02/2024 | 3.18.0 | MIS-28-021-21 | UPDATE | Category | Utilization | N/A |
02/02/2024 | 3.18.0 | MIS-28-021-21 | UPDATE | For ta comprehensive | TA- Inferential | No |
02/02/2024 | 3.18.0 | MIS-28-021-21 | UPDATE | For ta inferential | Yes | No |
02/02/2024 | 3.18.0 | MIS-28-021-21 | UPDATE | Ta min | 0 | |
02/02/2024 | 3.18.0 | MIS-28-021-21 | UPDATE | Ta max | 0.02 | |
11/15/2023 | 3.16.0 | MIS-28-018-18 | UPDATE | Measure name | % missing: OT-RX-CLAIM-QUANTITY-ACTUAL (CRX00003) | % missing: PRESCRIPTION-QUANTITY-ACTUAL (CRX00003) |
11/15/2023 | 3.16.0 | MIS-28-007-7 | UPDATE | Measure name | % missing: DISPENSE-FEE (CRX00003) | % missing: DISPENSE-FEE-SUBMITTED (CRX00003) |
11/15/2023 | 3.16.0 | MIS-28-005-5 | UPDATE | Measure name | % missing: COPAY-AMT (CRX00003) | % missing: BENEFICIARY-COPAYMENT-PAID-AMOUNT (CRX00003) |
06/19/2024 | 3.27.0 | MIS-28-003-3 | UPDATE | Ta min | 0 | |
06/19/2024 | 3.27.0 | MIS-28-003-3 | UPDATE | Ta max | 0.02 | |
06/19/2024 | 3.27.0 | MIS-28-003-3 | UPDATE | Threshold minimum | N/A | 0 |
06/19/2024 | 3.27.0 | MIS-28-003-3 | UPDATE | Threshold maximum | N/A | 0.02 |
06/19/2024 | 3.27.0 | MIS-27-027-27 | UPDATE | Threshold minimum | TBD | N/A |
06/19/2024 | 3.27.0 | MIS-27-027-27 | UPDATE | Threshold maximum | TBD | N/A |
11/15/2023 | 3.16.0 | MIS-27-023-23 | UPDATE | Priority | Critical | N/A |
11/15/2023 | 3.16.0 | MIS-27-023-23 | UPDATE | Category | File integrity | N/A |
11/15/2023 | 3.16.0 | MIS-27-023-23 | UPDATE | For ta comprehensive | TA- Inferential | No |
11/15/2023 | 3.16.0 | MIS-27-023-23 | UPDATE | For ta inferential | Yes | No |
11/15/2023 | 3.16.0 | MIS-27-023-23 | UPDATE | Ta min | 0 | |
11/15/2023 | 3.16.0 | MIS-27-023-23 | UPDATE | Ta max | 0.02 | |
11/15/2023 | 3.16.0 | MIS-27-023-23 | UPDATE | Annotation | Numeric | N/A |
11/15/2023 | 3.16.0 | MIS-27-023-23 | UPDATE | Specification | STEP 1: Active non-duplicate RX claims during DQ report monthDefine the RX claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 2: Medicaid or S-CHIP FFS: Original and Replacement, Paid ClaimsOf 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" or "4"STEP 3: Missing data elementOf the claims that meet the criteria from STEP 2, select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 4: Calculate percentageDivide the count of claims from STEP 3 by the count of claims from STEP 2 | N/A |
02/02/2024 | 3.18.0 | MIS-27-014-14 | UPDATE | Priority | High | N/A |
02/02/2024 | 3.18.0 | MIS-27-014-14 | UPDATE | Category | Expenditures | N/A |
02/02/2024 | 3.18.0 | MIS-27-014-14 | UPDATE | For ta comprehensive | TA- Inferential | No |
02/02/2024 | 3.18.0 | MIS-27-014-14 | UPDATE | For ta inferential | Yes | No |
02/02/2024 | 3.18.0 | MIS-27-014-14 | UPDATE | Ta min | 0 | |
02/02/2024 | 3.18.0 | MIS-27-014-14 | UPDATE | Ta max | 0.02 | |
06/19/2024 | 3.27.0 | MIS-27-005-5 | UPDATE | Priority | High | N/A |
06/19/2024 | 3.27.0 | MIS-27-005-5 | UPDATE | Category | Provider information | N/A |
06/19/2024 | 3.27.0 | MIS-27-005-5 | UPDATE | For ta comprehensive | TA- Inferential | No |
06/19/2024 | 3.27.0 | MIS-27-005-5 | UPDATE | For ta inferential | Yes | No |
06/19/2024 | 3.27.0 | MIS-27-005-5 | UPDATE | Ta min | 0 | |
06/19/2024 | 3.27.0 | MIS-27-005-5 | UPDATE | Ta max | 0.02 | |
06/19/2024 | 3.27.0 | MIS-27-005-5 | UPDATE | Annotation | Character | N/A |
06/19/2024 | 3.27.0 | MIS-27-005-5 | UPDATE | Specification | STEP 1: Active non-duplicate RX claims during DQ report monthDefine the RX claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 2: Medicaid or S-CHIP FFS: Original and Replacement, Paid ClaimsOf 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" or "4"STEP 3: Missing data elementOf the claims that meet the criteria from STEP 2, select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 4: Calculate percentageDivide the count of claims from STEP 3 by the count of claims from STEP 2 | N/A |
06/19/2024 | 3.27.0 | MIS-27-004-4 | UPDATE | Priority | High | N/A |
06/19/2024 | 3.27.0 | MIS-27-004-4 | UPDATE | Category | Provider information | N/A |
06/19/2024 | 3.27.0 | MIS-27-004-4 | UPDATE | For ta comprehensive | TA- Inferential | No |
06/19/2024 | 3.27.0 | MIS-27-004-4 | UPDATE | For ta inferential | Yes | No |
06/19/2024 | 3.27.0 | MIS-27-004-4 | UPDATE | Ta min | 0 | |
06/19/2024 | 3.27.0 | MIS-27-004-4 | UPDATE | Ta max | 0.02 | |
06/19/2024 | 3.27.0 | MIS-27-004-4 | UPDATE | Annotation | Character | N/A |
06/19/2024 | 3.27.0 | MIS-27-004-4 | UPDATE | Specification | STEP 1: Active non-duplicate RX claims during DQ report monthDefine the RX claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 2: Medicaid or S-CHIP FFS: Original and Replacement, Paid ClaimsOf 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" or "4"STEP 3: Missing data elementOf the claims that meet the criteria from STEP 2, select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 4: Calculate percentageDivide the count of claims from STEP 3 by the count of claims from STEP 2 | N/A |
11/15/2023 | 3.16.0 | MIS-27-003-3 | UPDATE | Measure name | % missing: BENEFICIARY-DEDUCTIBLE-AMOUNT (CRX00002) | % missing: TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT (CRX00002) |
11/15/2023 | 3.16.0 | MIS-27-002-2 | UPDATE | Measure name | % missing: BENEFICIARY-COPAYMENT-AMOUNT (CRX00002) | % missing: TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT (CRX00002) |
11/15/2023 | 3.16.0 | MIS-27-001-1 | UPDATE | Measure name | % missing: BENEFICIARY-COINSURANCE-AMOUNT (CRX00002) | % missing: TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT (CRX00002) |
02/02/2024 | 3.18.0 | MIS-26-031-31 | UPDATE | Priority | High | N/A |
02/02/2024 | 3.18.0 | MIS-26-031-31 | UPDATE | Category | Utilization | N/A |
02/02/2024 | 3.18.0 | MIS-26-031-31 | UPDATE | For ta comprehensive | TA- Inferential | No |
02/02/2024 | 3.18.0 | MIS-26-031-31 | UPDATE | For ta inferential | Yes | No |
02/02/2024 | 3.18.0 | MIS-26-031-31 | UPDATE | Ta min | 0 | |
02/02/2024 | 3.18.0 | MIS-26-031-31 | UPDATE | Ta max | 0.02 | |
11/15/2023 | 3.16.0 | MIS-26-007-7 | UPDATE | Priority | High | N/A |
11/15/2023 | 3.16.0 | MIS-26-007-7 | UPDATE | Category | Utilization | N/A |
11/15/2023 | 3.16.0 | MIS-26-007-7 | UPDATE | For ta comprehensive | TA- Inferential | No |
11/15/2023 | 3.16.0 | MIS-26-007-7 | UPDATE | For ta inferential | Yes | No |
11/15/2023 | 3.16.0 | MIS-26-007-7 | UPDATE | Ta min | 0 | |
11/15/2023 | 3.16.0 | MIS-26-007-7 | UPDATE | Ta max | 0.02 | |
11/15/2023 | 3.16.0 | MIS-26-007-7 | UPDATE | Annotation | Numeric | N/A |
11/15/2023 | 3.16.0 | MIS-26-007-7 | UPDATE | Specification | STEP 1: Active non-duplicate OT claims during DQ report monthDefine the OT claims universe at the header level by importing both headers and lines that satisfy the following criteria:For Headers:1. Reporting Period from 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 FFS: Original and Replacement, Paid ClaimsOf 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" or "4"STEP 3: Missing data elementOf the claims that meet the criteria from STEP 2, select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 4: Calculate percentageDivide the count of claim lines from STEP 3 by the count of claim lines from STEP 2 | N/A |
11/15/2023 | 3.16.0 | MIS-26-006-6 | UPDATE | Measure name | % missing: COPAY-AMT (COT00003) | % missing: BENEFICIARY-COPAYMENT-PAID-AMOUNT (COT00003) |
06/19/2024 | 3.27.0 | MIS-26-005-5 | UPDATE | Ta min | 0 | |
06/19/2024 | 3.27.0 | MIS-26-005-5 | UPDATE | Ta max | 0.1 | |
06/19/2024 | 3.27.0 | MIS-26-005-5 | UPDATE | Threshold minimum | N/A | 0 |
06/19/2024 | 3.27.0 | MIS-26-005-5 | UPDATE | Threshold maximum | N/A | 0.1 |
11/15/2023 | 3.16.0 | MIS-26-003-3 | UPDATE | Priority | High | N/A |
11/15/2023 | 3.16.0 | MIS-26-003-3 | UPDATE | Category | Utilization | N/A |
11/15/2023 | 3.16.0 | MIS-26-003-3 | UPDATE | For ta comprehensive | TA- Inferential | No |
11/15/2023 | 3.16.0 | MIS-26-003-3 | UPDATE | For ta inferential | Yes | No |
11/15/2023 | 3.16.0 | MIS-26-003-3 | UPDATE | Ta min | 0 | |
11/15/2023 | 3.16.0 | MIS-26-003-3 | UPDATE | Ta max | 0 | |
11/15/2023 | 3.16.0 | MIS-26-003-3 | UPDATE | Threshold maximum | 0 | 0.02 |
11/15/2023 | 3.16.0 | MIS-26-003-3 | UPDATE | Annotation | Numeric | N/A |
11/15/2023 | 3.16.0 | MIS-26-003-3 | UPDATE | Specification | STEP 1: Active non-duplicate OT claims during DQ report monthDefine the OT claims universe at the header level by importing both headers and lines that satisfy the following criteria:For Headers:1. Reporting Period from 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 FFS: Original and Replacement, Paid ClaimsOf 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" or "4"STEP 3: Missing data elementOf the claims that meet the criteria from STEP 2, select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 4: Calculate percentageDivide the count of claim lines from STEP 3 by the count of claim lines from STEP 2 | N/A |
11/15/2023 | 3.16.0 | MIS-26-002-20 | UPDATE | Measure name | % missing: OT-RX-CLAIM-QUANTITY-ACTUAL (COT00003) | % missing: SERVICE-QUANTITY-ACTUAL (COT00003) |
06/19/2024 | 3.27.0 | MIS-26-001-10 | UPDATE | Threshold minimum | TBD | N/A |
06/19/2024 | 3.27.0 | MIS-26-001-10 | UPDATE | Threshold maximum | TBD | N/A |
11/15/2023 | 3.16.0 | MIS-25-016-16 | UPDATE | Priority | Critical | N/A |
11/15/2023 | 3.16.0 | MIS-25-016-16 | UPDATE | Category | File integrity | N/A |
11/15/2023 | 3.16.0 | MIS-25-016-16 | UPDATE | For ta comprehensive | TA- Inferential | No |
11/15/2023 | 3.16.0 | MIS-25-016-16 | UPDATE | For ta inferential | Yes | No |
11/15/2023 | 3.16.0 | MIS-25-016-16 | UPDATE | Ta min | 0 | |
11/15/2023 | 3.16.0 | MIS-25-016-16 | UPDATE | Ta max | 0.02 | |
11/15/2023 | 3.16.0 | MIS-25-016-16 | UPDATE | Annotation | Numeric | N/A |
11/15/2023 | 3.16.0 | MIS-25-016-16 | UPDATE | Specification | STEP 1: Active non-duplicate OT claims during DQ report monthDefine the OT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 2: Medicaid or S-CHIP FFS: Original and Replacement, Paid ClaimsOf 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" or "4"STEP 3: Missing data elementOf the claims that meet the criteria from STEP 2, select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 4: Calculate percentageDivide the count of claims from STEP 3 by the count of claims from STEP 2 | N/A |
06/19/2024 | 3.27.0 | MIS-25-007-7 | UPDATE | Priority | High | N/A |
06/19/2024 | 3.27.0 | MIS-25-007-7 | UPDATE | Category | Provider information | N/A |
06/19/2024 | 3.27.0 | MIS-25-007-7 | UPDATE | For ta comprehensive | TA- Inferential | No |
06/19/2024 | 3.27.0 | MIS-25-007-7 | UPDATE | For ta inferential | Yes | No |
06/19/2024 | 3.27.0 | MIS-25-007-7 | UPDATE | Ta min | 0 | |
06/19/2024 | 3.27.0 | MIS-25-007-7 | UPDATE | Ta max | 0.02 | |
06/19/2024 | 3.27.0 | MIS-25-007-7 | UPDATE | Annotation | Character | N/A |
06/19/2024 | 3.27.0 | MIS-25-007-7 | UPDATE | Specification | STEP 1: Active non-duplicate OT claims during DQ report monthDefine the OT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 2: Medicaid or S-CHIP FFS: Original and Replacement, Paid ClaimsOf 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" or "4"STEP 3: Missing data elementOf the claims that meet the criteria from STEP 2, select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 4: Calculate percentageDivide the count of claims from STEP 3 by the count of claims from STEP 2 | N/A |
06/19/2024 | 3.27.0 | MIS-25-005-5 | UPDATE | Priority | High | Medium |
06/19/2024 | 3.27.0 | MIS-25-005-5 | UPDATE | Ta max | 0.15 | 0.3 |
06/19/2024 | 3.27.0 | MIS-25-005-5 | UPDATE | Threshold maximum | 0.15 | 0.3 |
11/15/2023 | 3.16.0 | MIS-25-004-4 | UPDATE | Measure name | % missing: BENEFICIARY-DEDUCTIBLE-AMOUNT (COT00002) | % missing: TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT (COT00002) |
11/15/2023 | 3.16.0 | MIS-25-003-3 | UPDATE | Measure name | % missing: BENEFICIARY-COPAYMENT-AMOUNT (COT00002) | % missing: TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT (COT00002) |
02/02/2024 | 3.18.0 | MIS-25-002-20 | UPDATE | Priority | High | N/A |
02/02/2024 | 3.18.0 | MIS-25-002-20 | UPDATE | Category | Expenditures | N/A |
02/02/2024 | 3.18.0 | MIS-25-002-20 | UPDATE | For ta comprehensive | TA- Inferential | No |
02/02/2024 | 3.18.0 | MIS-25-002-20 | UPDATE | For ta inferential | Yes | No |
02/02/2024 | 3.18.0 | MIS-25-002-20 | UPDATE | Ta min | 0 | |
02/02/2024 | 3.18.0 | MIS-25-002-20 | UPDATE | Ta max | 0.02 | |
11/15/2023 | 3.16.0 | MIS-25-002-2 | UPDATE | Measure name | % missing: BENEFICIARY-COINSURANCE-AMOUNT (COT00002) | % missing: TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT (COT00002) |
11/15/2023 | 3.16.0 | MIS-25-001-1 | UPDATE | Priority | Critical | N/A |
11/15/2023 | 3.16.0 | MIS-25-001-1 | UPDATE | Category | File integrity | N/A |
11/15/2023 | 3.16.0 | MIS-25-001-1 | UPDATE | For ta comprehensive | TA- Inferential | No |
11/15/2023 | 3.16.0 | MIS-25-001-1 | UPDATE | For ta inferential | Yes | No |
11/15/2023 | 3.16.0 | MIS-25-001-1 | UPDATE | Ta min | 0 | |
11/15/2023 | 3.16.0 | MIS-25-001-1 | UPDATE | Ta max | 0.02 | |
11/15/2023 | 3.16.0 | MIS-25-001-1 | UPDATE | Annotation | Numeric | N/A |
11/15/2023 | 3.16.0 | MIS-25-001-1 | UPDATE | Specification | STEP 1: Active non-duplicate OT claims during DQ report monthDefine the OT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 2: Medicaid or S-CHIP FFS: Original and Replacement, Paid ClaimsOf 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" or "4"STEP 3: Missing data elementOf the claims that meet the criteria from STEP 2, select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 4: Calculate percentageDivide the count of claims from STEP 3 by the count of claims from STEP 2 | N/A |
02/02/2024 | 3.18.0 | MIS-24-018-18 | UPDATE | Priority | High | N/A |
02/02/2024 | 3.18.0 | MIS-24-018-18 | UPDATE | Category | Utilization | N/A |
02/02/2024 | 3.18.0 | MIS-24-018-18 | UPDATE | For ta comprehensive | TA- Inferential | No |
02/02/2024 | 3.18.0 | MIS-24-018-18 | UPDATE | For ta inferential | Yes | No |
02/02/2024 | 3.18.0 | MIS-24-018-18 | UPDATE | Ta min | 0 | |
02/02/2024 | 3.18.0 | MIS-24-018-18 | UPDATE | Ta max | 0.02 | |
06/19/2024 | 3.27.0 | MIS-24-012-12 | UPDATE | Ta min | 0 | |
06/19/2024 | 3.27.0 | MIS-24-012-12 | UPDATE | Ta max | 0.02 | |
06/19/2024 | 3.27.0 | MIS-24-012-12 | UPDATE | Threshold minimum | N/A | 0 |
06/19/2024 | 3.27.0 | MIS-24-012-12 | UPDATE | Threshold maximum | N/A | 0.02 |
11/15/2023 | 3.16.0 | MIS-24-004-4 | UPDATE | Priority | High | N/A |
11/15/2023 | 3.16.0 | MIS-24-004-4 | UPDATE | Category | Utilization | N/A |
11/15/2023 | 3.16.0 | MIS-24-004-4 | UPDATE | For ta comprehensive | TA- Inferential | No |
11/15/2023 | 3.16.0 | MIS-24-004-4 | UPDATE | For ta inferential | Yes | No |
11/15/2023 | 3.16.0 | MIS-24-004-4 | UPDATE | Ta min | 0 | |
11/15/2023 | 3.16.0 | MIS-24-004-4 | UPDATE | Ta max | 0.02 | |
11/15/2023 | 3.16.0 | MIS-24-004-4 | UPDATE | Annotation | Numeric | N/A |
11/15/2023 | 3.16.0 | MIS-24-004-4 | UPDATE | Specification | STEP 1: Active non-duplicate LT claims during DQ report monthDefine the LT claims universe at the header level by importing both headers and lines that satisfy the following criteria:For Headers:1. Reporting Period from 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 FFS: Original and Replacement, Paid ClaimsOf 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" or "4"STEP 3: Missing data elementOf the claims that meet the criteria from STEP 2, select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 4: Calculate percentageDivide the count of claim lines from STEP 3 by the count of claim lines from STEP 2 | N/A |
11/15/2023 | 3.16.0 | MIS-24-003-3 | UPDATE | Priority | High | N/A |
11/15/2023 | 3.16.0 | MIS-24-003-3 | UPDATE | Category | Utilization | N/A |
11/15/2023 | 3.16.0 | MIS-24-003-3 | UPDATE | For ta comprehensive | TA- Inferential | No |
11/15/2023 | 3.16.0 | MIS-24-003-3 | UPDATE | For ta inferential | Yes | No |
11/15/2023 | 3.16.0 | MIS-24-003-3 | UPDATE | Ta min | 0 | |
11/15/2023 | 3.16.0 | MIS-24-003-3 | UPDATE | Ta max | 0 | |
11/15/2023 | 3.16.0 | MIS-24-003-3 | UPDATE | Threshold maximum | 0 | 0.02 |
11/15/2023 | 3.16.0 | MIS-24-003-3 | UPDATE | Annotation | Numeric | N/A |
11/15/2023 | 3.16.0 | MIS-24-003-3 | UPDATE | Specification | STEP 1: Active non-duplicate LT claims during DQ report monthDefine the LT claims universe at the header level by importing both headers and lines that satisfy the following criteria:For Headers:1. Reporting Period from 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 FFS: Original and Replacement, Paid ClaimsOf 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" or "4"STEP 3: Missing data elementOf the claims that meet the criteria from STEP 2, select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 4: Calculate percentageDivide the count of claim lines from STEP 3 by the count of claim lines from STEP 2 | N/A |
02/02/2024 | 3.18.0 | MIS-23-026-26 | UPDATE | Priority | High | N/A |
02/02/2024 | 3.18.0 | MIS-23-026-26 | UPDATE | Category | Expenditures | N/A |
02/02/2024 | 3.18.0 | MIS-23-026-26 | UPDATE | For ta comprehensive | TA- Inferential | No |
02/02/2024 | 3.18.0 | MIS-23-026-26 | UPDATE | For ta inferential | Yes | No |
02/02/2024 | 3.18.0 | MIS-23-026-26 | UPDATE | Ta min | 0 | |
02/02/2024 | 3.18.0 | MIS-23-026-26 | UPDATE | Ta max | 0.02 | |
11/15/2023 | 3.16.0 | MIS-23-018-18 | UPDATE | Priority | Critical | N/A |
11/15/2023 | 3.16.0 | MIS-23-018-18 | UPDATE | Category | File integrity | N/A |
11/15/2023 | 3.16.0 | MIS-23-018-18 | UPDATE | For ta comprehensive | TA- Inferential | No |
11/15/2023 | 3.16.0 | MIS-23-018-18 | UPDATE | For ta inferential | Yes | No |
11/15/2023 | 3.16.0 | MIS-23-018-18 | UPDATE | Ta min | 0 | |
11/15/2023 | 3.16.0 | MIS-23-018-18 | UPDATE | Ta max | 0.02 | |
11/15/2023 | 3.16.0 | MIS-23-018-18 | UPDATE | Annotation | Numeric | N/A |
11/15/2023 | 3.16.0 | MIS-23-018-18 | UPDATE | Specification | STEP 1: Active non-duplicate LT claims during DQ report monthDefine the LT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 2: Medicaid or S-CHIP FFS or Encounter: Original and Replacement, Paid ClaimsOf 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" or "4"STEP 3: Missing data elementOf the claims that meet the criteria from STEP 2, select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 4: Calculate percentageDivide the count of claims from STEP 3 by the count of claims from STEP 2 | N/A |
06/19/2024 | 3.27.0 | MIS-23-009-9 | UPDATE | Priority | High | N/A |
06/19/2024 | 3.27.0 | MIS-23-009-9 | UPDATE | Category | Provider information | N/A |
06/19/2024 | 3.27.0 | MIS-23-009-9 | UPDATE | For ta comprehensive | TA- Inferential | No |
06/19/2024 | 3.27.0 | MIS-23-009-9 | UPDATE | For ta inferential | Yes | No |
06/19/2024 | 3.27.0 | MIS-23-009-9 | UPDATE | Ta min | 0 | |
06/19/2024 | 3.27.0 | MIS-23-009-9 | UPDATE | Ta max | 0.02 | |
06/19/2024 | 3.27.0 | MIS-23-009-9 | UPDATE | Annotation | Character | N/A |
06/19/2024 | 3.27.0 | MIS-23-009-9 | UPDATE | Specification | STEP 1: Active non-duplicate LT claims during DQ report monthDefine the LT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 2: Medicaid or S-CHIP FFS or Encounter: Original and Replacement, Paid ClaimsOf 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" or "4"STEP 3: Missing data elementOf the claims that meet the criteria from STEP 2, select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 4: Calculate percentageDivide the count of claims from STEP 3 by the count of claims from STEP 2 | N/A |
06/19/2024 | 3.27.0 | MIS-23-007-7 | UPDATE | Priority | High | N/A |
06/19/2024 | 3.27.0 | MIS-23-007-7 | UPDATE | Category | Provider information | N/A |
06/19/2024 | 3.27.0 | MIS-23-007-7 | UPDATE | For ta comprehensive | TA- Inferential | No |
06/19/2024 | 3.27.0 | MIS-23-007-7 | UPDATE | For ta inferential | Yes | No |
06/19/2024 | 3.27.0 | MIS-23-007-7 | UPDATE | Ta min | 0 | |
06/19/2024 | 3.27.0 | MIS-23-007-7 | UPDATE | Ta max | 0.02 | |
06/19/2024 | 3.27.0 | MIS-23-007-7 | UPDATE | Annotation | Character | N/A |
06/19/2024 | 3.27.0 | MIS-23-007-7 | UPDATE | Specification | STEP 1: Active non-duplicate LT claims during DQ report monthDefine the LT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 2: Medicaid or S-CHIP FFS or Encounter: Original and Replacement, Paid ClaimsOf 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" or "4"STEP 3: Missing data elementOf the claims that meet the criteria from STEP 2, select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 4: Calculate percentageDivide the count of claims from STEP 3 by the count of claims from STEP 2 | N/A |
11/15/2023 | 3.16.0 | MIS-23-006-6 | UPDATE | Measure name | % missing: BENEFICIARY-DEDUCTIBLE-AMOUNT (CLT00002) | % missing: TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT (CLT00002) |
11/15/2023 | 3.16.0 | MIS-23-005-5 | UPDATE | Measure name | % missing: BENEFICIARY-COPAYMENT-AMOUNT (CLT00002) | % missing: TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT (CLT00002) |
11/15/2023 | 3.16.0 | MIS-23-004-4 | UPDATE | Measure name | % missing: BENEFICIARY-COINSURANCE-AMOUNT (CLT00002) | % missing: TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT (CLT00002) |
11/15/2023 | 3.16.0 | MIS-23-003-3 | UPDATE | Priority | Critical | N/A |
11/15/2023 | 3.16.0 | MIS-23-003-3 | UPDATE | Category | File integrity | N/A |
11/15/2023 | 3.16.0 | MIS-23-003-3 | UPDATE | For ta comprehensive | TA- Inferential | No |
11/15/2023 | 3.16.0 | MIS-23-003-3 | UPDATE | For ta inferential | Yes | No |
11/15/2023 | 3.16.0 | MIS-23-003-3 | UPDATE | Ta min | 0 | |
11/15/2023 | 3.16.0 | MIS-23-003-3 | UPDATE | Ta max | 0.02 | |
11/15/2023 | 3.16.0 | MIS-23-003-3 | UPDATE | Annotation | Numeric | N/A |
11/15/2023 | 3.16.0 | MIS-23-003-3 | UPDATE | Specification | STEP 1: Active non-duplicate LT claims during DQ report monthDefine the LT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 2: Medicaid or S-CHIP FFS or Encounter: Original and Replacement, Paid ClaimsOf 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" or "4"STEP 3: Missing data elementOf the claims that meet the criteria from STEP 2, select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 4: Calculate percentageDivide the count of claims from STEP 3 by the count of claims from STEP 2 | N/A |
02/02/2024 | 3.18.0 | MIS-22-018-18 | UPDATE | Priority | High | N/A |
02/02/2024 | 3.18.0 | MIS-22-018-18 | UPDATE | Category | Utilization | N/A |
02/02/2024 | 3.18.0 | MIS-22-018-18 | UPDATE | For ta comprehensive | TA- Inferential | No |
02/02/2024 | 3.18.0 | MIS-22-018-18 | UPDATE | For ta inferential | Yes | No |
02/02/2024 | 3.18.0 | MIS-22-018-18 | UPDATE | Ta min | 0 | |
02/02/2024 | 3.18.0 | MIS-22-018-18 | UPDATE | Ta max | 0.02 | |
06/19/2024 | 3.27.0 | MIS-22-012-12 | UPDATE | Ta min | 0 | |
06/19/2024 | 3.27.0 | MIS-22-012-12 | UPDATE | Ta max | 0.02 | |
06/19/2024 | 3.27.0 | MIS-22-012-12 | UPDATE | Threshold minimum | N/A | 0 |
06/19/2024 | 3.27.0 | MIS-22-012-12 | UPDATE | Threshold maximum | N/A | 0.02 |
11/15/2023 | 3.16.0 | MIS-22-004-4 | UPDATE | Priority | Critical | N/A |
11/15/2023 | 3.16.0 | MIS-22-004-4 | UPDATE | Category | File integrity | N/A |
11/15/2023 | 3.16.0 | MIS-22-004-4 | UPDATE | For ta comprehensive | TA- Inferential | No |
11/15/2023 | 3.16.0 | MIS-22-004-4 | UPDATE | For ta inferential | Yes | No |
11/15/2023 | 3.16.0 | MIS-22-004-4 | UPDATE | Ta min | 0 | |
11/15/2023 | 3.16.0 | MIS-22-004-4 | UPDATE | Ta max | 0.02 | |
11/15/2023 | 3.16.0 | MIS-22-004-4 | UPDATE | Annotation | Numeric | N/A |
11/15/2023 | 3.16.0 | MIS-22-004-4 | UPDATE | Specification | STEP 1: Active non-duplicate IP claims during DQ report monthDefine the IP claims universe at the header level by importing both headers and lines that satisfy the following criteria:For Headers:1. Reporting Period from 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 FFS: Original and Replacement, Paid ClaimsOf 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" or "4"STEP 3: Missing data elementOf the claims that meet the criteria from STEP 2, select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 4: Calculate percentageDivide the count of claim lines from STEP 3 by the count of claim lines from STEP 2 | N/A |
11/15/2023 | 3.16.0 | MIS-22-003-3 | UPDATE | Priority | Critical | N/A |
11/15/2023 | 3.16.0 | MIS-22-003-3 | UPDATE | Category | File integrity | N/A |
11/15/2023 | 3.16.0 | MIS-22-003-3 | UPDATE | For ta comprehensive | TA- Inferential | No |
11/15/2023 | 3.16.0 | MIS-22-003-3 | UPDATE | For ta inferential | Yes | No |
11/15/2023 | 3.16.0 | MIS-22-003-3 | UPDATE | Ta min | 0 | |
11/15/2023 | 3.16.0 | MIS-22-003-3 | UPDATE | Ta max | 0.02 | |
11/15/2023 | 3.16.0 | MIS-22-003-3 | UPDATE | Annotation | Numeric | N/A |
11/15/2023 | 3.16.0 | MIS-22-003-3 | UPDATE | Specification | STEP 1: Active non-duplicate IP claims during DQ report monthDefine the IP claims universe at the header level by importing both headers and lines that satisfy the following criteria:For Headers:1. Reporting Period from 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 FFS: Original and Replacement, Paid ClaimsOf 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" or "4"STEP 3: Missing data elementOf the claims that meet the criteria from STEP 2, select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 4: Calculate percentageDivide the count of claim lines from STEP 3 by the count of claim lines from STEP 2 | N/A |
06/19/2024 | 3.27.0 | MIS-21-055-55 | UPDATE | Threshold minimum | TBD | N/A |
06/19/2024 | 3.27.0 | MIS-21-055-55 | UPDATE | Threshold maximum | TBD | N/A |
02/02/2024 | 3.18.0 | MIS-21-033-33 | UPDATE | Priority | High | N/A |
02/02/2024 | 3.18.0 | MIS-21-033-33 | UPDATE | Category | Expenditures | N/A |
02/02/2024 | 3.18.0 | MIS-21-033-33 | UPDATE | For ta comprehensive | TA- Inferential | No |
02/02/2024 | 3.18.0 | MIS-21-033-33 | UPDATE | For ta inferential | Yes | No |
02/02/2024 | 3.18.0 | MIS-21-033-33 | UPDATE | Ta min | 0 | |
02/02/2024 | 3.18.0 | MIS-21-033-33 | UPDATE | Ta max | 0.02 | |
06/19/2024 | 3.27.0 | MIS-21-010-10 | UPDATE | Priority | High | N/A |
06/19/2024 | 3.27.0 | MIS-21-010-10 | UPDATE | Category | Provider information | N/A |
06/19/2024 | 3.27.0 | MIS-21-010-10 | UPDATE | For ta comprehensive | TA- Inferential | No |
06/19/2024 | 3.27.0 | MIS-21-010-10 | UPDATE | For ta inferential | Yes | No |
06/19/2024 | 3.27.0 | MIS-21-010-10 | UPDATE | Ta min | 0 | |
06/19/2024 | 3.27.0 | MIS-21-010-10 | UPDATE | Ta max | 0.02 | |
06/19/2024 | 3.27.0 | MIS-21-010-10 | UPDATE | Annotation | Character | N/A |
06/19/2024 | 3.27.0 | MIS-21-010-10 | UPDATE | Specification | STEP 1: Active non-duplicate IP claims during DQ report monthDefine the IP claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 2: Medicaid or S-CHIP FFS: Original and Replacement, Paid ClaimsOf 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" or "4"STEP 3: Missing data elementOf the claims that meet the criteria from STEP 2, select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 4: Calculate percentageDivide the count of claims from STEP 3 by the count of claims from STEP 2 | N/A |
06/19/2024 | 3.27.0 | MIS-21-008-8 | UPDATE | Priority | High | N/A |
06/19/2024 | 3.27.0 | MIS-21-008-8 | UPDATE | Category | Provider information | N/A |
06/19/2024 | 3.27.0 | MIS-21-008-8 | UPDATE | For ta comprehensive | TA- Inferential | No |
06/19/2024 | 3.27.0 | MIS-21-008-8 | UPDATE | For ta inferential | Yes | No |
06/19/2024 | 3.27.0 | MIS-21-008-8 | UPDATE | Ta min | 0 | |
06/19/2024 | 3.27.0 | MIS-21-008-8 | UPDATE | Ta max | 0.02 | |
06/19/2024 | 3.27.0 | MIS-21-008-8 | UPDATE | Annotation | Character | N/A |
06/19/2024 | 3.27.0 | MIS-21-008-8 | UPDATE | Specification | STEP 1: Active non-duplicate IP claims during DQ report monthDefine the IP claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 2: Medicaid or S-CHIP FFS: Original and Replacement, Paid ClaimsOf 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" or "4"STEP 3: Missing data elementOf the claims that meet the criteria from STEP 2, select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 4: Calculate percentageDivide the count of claims from STEP 3 by the count of claims from STEP 2 | N/A |
11/15/2023 | 3.16.0 | MIS-21-007-7 | UPDATE | Measure name | % missing: BENEFICIARY-DEDUCTIBLE-AMOUNT (CIP00002) | % missing: TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT (CIP00002) |
11/15/2023 | 3.16.0 | MIS-21-006-6 | UPDATE | Measure name | % missing: BENEFICIARY-COPAYMENT-AMOUNT (CIP00002) | % missing: TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT (CIP00002) |
11/15/2023 | 3.16.0 | MIS-21-005-5 | UPDATE | Measure name | % missing: BENEFICIARY-COINSURANCE-AMOUNT (CIP00002) | % missing: TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT (CIP00002) |
11/15/2023 | 3.16.0 | MIS-21-001-1 | UPDATE | Priority | High | N/A |
11/15/2023 | 3.16.0 | MIS-21-001-1 | UPDATE | Category | Utilization | N/A |
11/15/2023 | 3.16.0 | MIS-21-001-1 | UPDATE | For ta comprehensive | TA- Inferential | No |
11/15/2023 | 3.16.0 | MIS-21-001-1 | UPDATE | For ta inferential | Yes | No |
11/15/2023 | 3.16.0 | MIS-21-001-1 | UPDATE | Ta min | 0 | |
11/15/2023 | 3.16.0 | MIS-21-001-1 | UPDATE | Ta max | 0.02 | |
11/15/2023 | 3.16.0 | MIS-21-001-1 | UPDATE | Annotation | Numeric | N/A |
11/15/2023 | 3.16.0 | MIS-21-001-1 | UPDATE | Specification | STEP 1: Active non-duplicate IP claims during DQ report monthDefine the IP claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 2: Medicaid or S-CHIP FFS: Original and Replacement, Paid ClaimsOf 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" or "4"STEP 3: Missing data elementOf the claims that meet the criteria from STEP 2, select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 4: Calculate percentageDivide the count of claims from STEP 3 by the count of claims from STEP 2 | N/A |
03/27/2024 | 3.22.0 | RULE-7379 | UPDATE | Measure name | % of non-zero paid claim lines with Title XXI funding with missing XXI-MBESCBES-CATEGORY-OF-SERVICE (CRX00003) | % of claim lines on non-zero paid claims with Title XXI funding with missing XXI-MBESCBES-CATEGORY-OF-SERVICE (CRX00003) |
03/27/2024 | 3.22.0 | RULE-7378 | UPDATE | Measure name | % of non-zero paid claim lines with Title XXI funding with missing XXI-MBESCBES-CATEGORY-OF-SERVICE (COT00003) | % of claim lines on non-zero paid claims with Title XXI funding with missing XXI-MBESCBES-CATEGORY-OF-SERVICE (COT00003) |
03/27/2024 | 3.22.0 | RULE-7377 | UPDATE | Measure name | % of non-zero paid claim lines with Title XXI funding with missing XXI-MBESCBES-CATEGORY-OF-SERVICE (CLT00003) | % of claim lines on non-zero paid claims with Title XXI funding with missing XXI-MBESCBES-CATEGORY-OF-SERVICE (CLT00003) |
03/27/2024 | 3.22.0 | RULE-7376 | UPDATE | Measure name | % of non-zero paid claim lines with Title XXI funding with missing XXI-MBESCBES-CATEGORY-OF-SERVICE (CIP00003) | % of claim lines on non-zero paid claims with Title XXI funding with missing XXI-MBESCBES-CATEGORY-OF-SERVICE (CIP00003) |
03/27/2024 | 3.22.0 | RULE-7375 | UPDATE | Measure name | % of non-zero paid claim lines with Title XIX funding with missing XIX-MBESCBES-CATEGORY-OF-SERVICE (CRX00003) | % of claim lines on non-zero paid claims with Title XIX funding with missing XIX-MBESCBES-CATEGORY-OF-SERVICE (CRX00003) |
03/27/2024 | 3.22.0 | RULE-7374 | UPDATE | Measure name | % of non-zero paid claim lines with Title XIX funding with missing XIX-MBESCBES-CATEGORY-OF-SERVICE (COT00003) | % of claim lines on non-zero paid claims with Title XIX funding with missing XIX-MBESCBES-CATEGORY-OF-SERVICE (COT00003) |
03/27/2024 | 3.22.0 | RULE-7373 | UPDATE | Measure name | % of non-zero paid claim lines with Title XIX funding with missing XIX-MBESCBES-CATEGORY-OF-SERVICE (CLT00003) | % of claim lines on non-zero paid claims with Title XIX funding with missing XIX-MBESCBES-CATEGORY-OF-SERVICE (CLT00003) |
03/27/2024 | 3.22.0 | RULE-7372 | UPDATE | Measure name | % of non-zero paid claim lines with Title XIX funding with missing XIX-MBESCBES-CATEGORY-OF-SERVICE (CIP00003) | % of claim lines on non-zero paid claims with Title XIX funding with missing XIX-MBESCBES-CATEGORY-OF-SERVICE (CIP00003) |
06/19/2024 | 3.27.0 | PRV-6-004-4 | UPDATE | Annotation | Calculate the percentage of submitting state provider IDs that have a facility group individual code indicating individual that are missing provider classification code | N/A |
06/19/2024 | 3.27.0 | PRV-6-004-4 | UPDATE | Specification | STEP 1: Provider enrolled on the last day of DQ report monthDefine the provider population from segment PROV-MEDICAID-ENROLLMENT-PRV00007 by keeping active records that satisfy the following criteria:1. PROV-MEDICAID-EFF-DATE <= last day of the reporting month2. PROV-MEDICAID-END-DATE >= last day of the reporting month OR missing3. SUBMITTING-STATE-PROV-ID is not missingSTEP 2: Provider attributes are active on last day of DQ report monthOf the providers that meet the criteria from STEP 1, further refine the population using segment PROVIDER-ATTRIBUTES-MAIN- PRV00002 by keeping records that satisfy the following criteria:1. PROV-ATTRIBUTES-EFF-DATE <= last day of the reporting month2. PROV-ATTRIBUTES-END-DATE >= last day of the reporting month3. SUBMITTING-STATE-PROV-ID is not missingSTEP 3: Provider is an individualOf the SUBMITTING-STATE-PROV-IDs that meet the criteria from STEP 2, further refine the population by keeping records that satisfy the following criteria:1. FACILITY-GROUP-INDIVIDUAL-CODE = "03"STEP 4: Provider taxonomy is active on the last day of DQ report monthOf the providers that meet the criteria from STEP 3, further refine the population using segment PROVIDER-TAXONOMY-CLASSIFICATION-PRV00006 by keeping records that satisfy the following criteria:1a. PROV-TAXONOMY-CLASSIFICATION-EFF-DATE <= last day of the reporting month2a. PROV-TAXONOMY-CLASSIFICATION-END-DATE >= last day of the reporting month OR missingOR1b. PROV-TAXONOMY-CLASSIFICATION-EFF-DATE is missing2b. PROV-TAXONOMY-CLASSIFICATION-END-DATE is missingSTEP 5: Provider Classification Code is missingOf the SUBMITTING-STATE-PROV-IDs that meet the criteria from STEP 4, further refine the population using segment by keeping records that meet the following criteria:1. PROVIDER-CLASSIFICATION-CODE is always missingSTEP 6: Calculate percentageDivide the count of unique SUBMITTING-STATE-PROVIDER-IDENTIFIER values from STEP 5 by the count of unique SUBMITTING-STATE-PROVIDER-IDENTIFIER values from STEP 3 | N/A |
06/19/2024 | 3.27.0 | PRV-6-003-3 | UPDATE | Annotation | Calculate the percentage of submitting state provider IDs that have a facility group individual code indicating facility or group that are missing provider classification code | N/A |
06/19/2024 | 3.27.0 | PRV-6-003-3 | UPDATE | Specification | STEP 1: Provider enrolled on the last day of DQ report monthDefine the provider population from segment PROV-MEDICAID-ENROLLMENT-PRV00007 by keeping active records that satisfy the following criteria:1. PROV-MEDICAID-EFF-DATE <= last day of the reporting month2. PROV-MEDICAID-END-DATE >= last day of the reporting month OR missing3. SUBMITTING-STATE-PROV-ID is not missingSTEP 2: Provider attributes are active on last day of DQ report monthOf the providers that meet the criteria from STEP 1, further refine the population using segment PROVIDER-ATTRIBUTES-MAIN- PRV00002 by keeping records that satisfy the following criteria:1. PROV-ATTRIBUTES-EFF-DATE <= last day of the reporting month2. PROV-ATTRIBUTES-END-DATE >= last day of the reporting month or missing3. SUBMITTING-STATE-PROV-ID is not missingSTEP 3: Provider is a facility or groupOf the SUBMITTING-STATE-PROV-IDs that meet the criteria from STEP 2, further refine the population by keeping records that satisfy the following criteria:1. FACILITY-GROUP-INDIVIDUAL-CODE = "01" or "02"STEP 4: Provider taxonomy is active on the last day of DQ report monthOf the providers that meet the criteria from STEP 3, further refine the population using segment PROVIDER-TAXONOMY-CLASSIFICATION-PRV00006 by keeping records that satisfy the following criteria:1a. PROV-TAXONOMY-CLASSIFICATION-EFF-DATE <= last day of the reporting month2a. PROV-TAXONOMY-CLASSIFICATION-END-DATE >= last day of the reporting month OR missingOR1b. PROV-TAXONOMY-CLASSIFICATION-EFF-DATE is missing2b. PROV-TAXONOMY-CLASSIFICATION-END-DATE is missingSTEP 5: Provider Classification Code is missingOf the SUBMITTING-STATE-PROV-IDs that meet the criteria from STEP 4, further refine the population by keeping records that meet the following criteria:1. PROVIDER-CLASSIFICATION-CODE is always missingSTEP 6: Calculate percentageDivide the count of unique SUBMITTING-STATE-PROVIDER-IDENTIFIER values from STEP 5 by the count of unique SUBMITTING-STATE-PROVIDER-IDENTIFIER values from STEP 3 | N/A |
06/19/2024 | 3.27.0 | PRV-6-002-2 | UPDATE | Priority | N/A | Medium |
06/19/2024 | 3.27.0 | PRV-6-002-2 | UPDATE | Category | N/A | Provider identifiers |
06/19/2024 | 3.27.0 | PRV-6-002-2 | UPDATE | For ta comprehensive | No | TA- Inferential |
06/19/2024 | 3.27.0 | PRV-6-002-2 | UPDATE | For ta inferential | No | Yes |
06/19/2024 | 3.27.0 | PRV-6-002-2 | UPDATE | Ta min | 0 | |
06/19/2024 | 3.27.0 | PRV-6-002-2 | UPDATE | Ta max | 0.1 | |
06/19/2024 | 3.27.0 | PRV-6-001-1 | UPDATE | Priority | N/A | Medium |
06/19/2024 | 3.27.0 | PRV-6-001-1 | UPDATE | Category | N/A | Provider identifiers |
06/19/2024 | 3.27.0 | PRV-6-001-1 | UPDATE | For ta comprehensive | No | TA- Inferential |
06/19/2024 | 3.27.0 | PRV-6-001-1 | UPDATE | For ta inferential | No | Yes |
06/19/2024 | 3.27.0 | PRV-6-001-1 | UPDATE | Ta min | 0 | |
06/19/2024 | 3.27.0 | PRV-6-001-1 | UPDATE | Ta max | 0.2 | |
06/19/2024 | 3.27.0 | PRV-6-001-1 | UPDATE | Threshold maximum | 0.1 | 0.2 |
11/15/2023 | 3.16.0 | FFS-49-004-16 | UPDATE | Priority | High | N/A |
11/15/2023 | 3.16.0 | FFS-49-004-16 | UPDATE | Category | Expenditures | N/A |
11/15/2023 | 3.16.0 | FFS-49-004-16 | UPDATE | For ta comprehensive | TA- Inferential | No |
11/15/2023 | 3.16.0 | FFS-49-004-16 | UPDATE | For ta inferential | Yes | No |
11/15/2023 | 3.16.0 | FFS-49-004-16 | UPDATE | Ta min | 0 | |
11/15/2023 | 3.16.0 | FFS-49-004-16 | UPDATE | Ta max | 0.01 | |
11/15/2023 | 3.16.0 | FFS-49-004-16 | UPDATE | Annotation | Calculate the percentage of Medicaid and S-CHIP FFS: original, paid RX claims that are paid at the line level where the sum of Medicaid paid amount from the lines does not equal total Medicaid paid amount from the header | N/A |
11/15/2023 | 3.16.0 | FFS-49-004-16 | UPDATE | Specification | STEP 1: Active non-duplicate paid RX claims during report monthDefine the RX claims universe at the header level by importing both headers and lines that satisfy the following criteria:For Headers:1. Reporting Period from 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 FFS: Original Paid ClaimsOf 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: Exclude childless headersOf the claim headers that meet the criteria from STEP 2, drop all headers that do not merge to at least one lineSTEP 4: Claims paid at the line levelOf claims that meet the criteria from STEP 3, further restrict them by the following criteria:1. PAYMENT-LEVEL-IND = "2"STEP 5: Sum Medicaid paid amount from the claim linesOf the claim lines that meet the criteria from STEP 4, sum the MEDICAID-PAID-AMT values to the header level**Note: Missing values are converted to 0 before calculating the sumSTEP 6: Sum does not match total Medicaid paid amountKeep the claims where the sum from STEP 5 does NOT equal the TOT-MEDICAID-PAID-AMT from the header record**Note: Missing values are converted to 0 before comparisonSTEP 7: Calculate the percentage for the measureDivide the count of header claims from STEP 6 by the count of header claims from STEP 4 | N/A |
11/15/2023 | 3.16.0 | FFS-49-003-15 | UPDATE | Priority | High | N/A |
11/15/2023 | 3.16.0 | FFS-49-003-15 | UPDATE | Category | Expenditures | N/A |
11/15/2023 | 3.16.0 | FFS-49-003-15 | UPDATE | For ta comprehensive | TA- Inferential | No |
11/15/2023 | 3.16.0 | FFS-49-003-15 | UPDATE | For ta inferential | Yes | No |
11/15/2023 | 3.16.0 | FFS-49-003-15 | UPDATE | Ta min | 0 | |
11/15/2023 | 3.16.0 | FFS-49-003-15 | UPDATE | Ta max | 0.01 | |
11/15/2023 | 3.16.0 | FFS-49-003-15 | UPDATE | Annotation | Calculate the percentage of Medicaid and S-CHIP FFS : original, paid OT claims that are paid at the line level where the sum of Medicaid paid amount from the lines does not equal total Medicaid paid amount from the header | N/A |
11/15/2023 | 3.16.0 | FFS-49-003-15 | UPDATE | Specification | STEP 1: Active non-duplicate paid OT claims during report monthDefine the OT claims universe at the header level by importing both headers and lines that satisfy the following criteria:For Headers:1. Reporting Period from 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 FFS: Original Paid ClaimsOf 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: Exclude childless headersOf the claim headers that meet the criteria from STEP 2, drop all headers that do not merge to at least one lineSTEP 4: Claims paid at the line levelOf claims that meet the criteria from STEP 3, further restrict them by the following criteria:1. PAYMENT-LEVEL-IND = "2"STEP 5: Sum Medicaid paid amount from the claim linesOf the claim lines that meet the criteria from STEP 4, sum the MEDICAID-PAID-AMT values to the header level**Note: Missing values are converted to 0 before calculating the sumSTEP 6: Sum does not match total Medicaid paid amountKeep the claims where the sum from STEP 5 does NOT equal the TOT-MEDICAID-PAID-AMT from the header record**Note: Missing values are converted to 0 before comparisonSTEP 7: Calculate the percentage for the measureDivide the count of header claims from STEP 6 by the count of header claims from STEP 4 | N/A |
11/15/2023 | 3.16.0 | FFS-49-002-14 | UPDATE | Priority | High | N/A |
11/15/2023 | 3.16.0 | FFS-49-002-14 | UPDATE | Category | Expenditures | N/A |
11/15/2023 | 3.16.0 | FFS-49-002-14 | UPDATE | For ta comprehensive | TA- Inferential | No |
11/15/2023 | 3.16.0 | FFS-49-002-14 | UPDATE | For ta inferential | Yes | No |
11/15/2023 | 3.16.0 | FFS-49-002-14 | UPDATE | Ta min | 0 | |
11/15/2023 | 3.16.0 | FFS-49-002-14 | UPDATE | Ta max | 0.01 | |
11/15/2023 | 3.16.0 | FFS-49-002-14 | UPDATE | Annotation | Calculate the percentage of Medicaid and S-CHIP FFS: original, paid LT claims that are paid at the line level where the sum of Medicaid paid amount from the lines does not equal total Medicaid paid amount from the header | N/A |
11/15/2023 | 3.16.0 | FFS-49-002-14 | UPDATE | Specification | STEP 1: Active non-duplicate paid LT claims during report monthDefine the LT claims universe at the header level by importing both headers and lines that satisfy the following criteria:For Headers:1. Reporting Period from 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 FFS: Original Paid ClaimsOf 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: Exclude childless headersOf the claim headers that meet the criteria from STEP 2, drop all headers that do not merge to at least one lineSTEP 4: Claims paid at the line levelOf claims that meet the criteria from STEP 3, further restrict them by the following criteria:1. PAYMENT-LEVEL-IND = "2"STEP 5: Sum Medicaid paid amount from the claim linesOf the claim lines that meet the criteria from STEP 4, sum the MEDICAID-PAID-AMT values to the header level**Note: Missing values are converted to 0 before calculating the sumSTEP 6: Sum does not match total Medicaid paid amountKeep the claims where the sum from STEP 5 does NOT equal the TOT-MEDICAID-PAID-AMT from the header record**Note: Missing values are converted to 0 before comparisonSTEP 7: Calculate the percentage for the measureDivide the count of header claims from STEP 6 by the count of header claims from STEP 4 | N/A |
11/15/2023 | 3.16.0 | FFS-49-001-13 | UPDATE | Priority | High | N/A |
11/15/2023 | 3.16.0 | FFS-49-001-13 | UPDATE | Category | Expenditures | N/A |
11/15/2023 | 3.16.0 | FFS-49-001-13 | UPDATE | For ta comprehensive | TA- Inferential | No |
11/15/2023 | 3.16.0 | FFS-49-001-13 | UPDATE | For ta inferential | Yes | No |
11/15/2023 | 3.16.0 | FFS-49-001-13 | UPDATE | Ta min | 0 | |
11/15/2023 | 3.16.0 | FFS-49-001-13 | UPDATE | Ta max | 0.01 | |
11/15/2023 | 3.16.0 | FFS-49-001-13 | UPDATE | Annotation | Calculate the percentage of Medicaid and S-CHIP FFS: original, paid IP claims that are paid at the line level where the sum of Medicaid paid amount from the lines does not equal total Medicaid paid amount from the header | N/A |
11/15/2023 | 3.16.0 | FFS-49-001-13 | UPDATE | Specification | STEP 1: Active non-duplicate paid IP claims during report monthDefine the IP claims universe at the header level by importing both headers and lines that satisfy the following criteria:For Headers:1. Reporting Period from 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 FFS: Original Paid ClaimsOf 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: Exclude childless headersOf the claim headers that meet the criteria from STEP 2, drop all headers that do not merge to at least one lineSTEP 4: Claims paid at the line levelOf claims that meet the criteria from STEP 3, further restrict them by the following criteria:1. PAYMENT-LEVEL-IND = "2"STEP 5: Sum Medicaid paid amount from the claim linesOf the claim lines that meet the criteria from STEP 4, sum the MEDICAID-PAID-AMT values to the header level**Note: Missing values are converted to 0 before calculating the sumSTEP 6: Sum does not match total Medicaid paid amountKeep the claims where the sum from STEP 5 does NOT equal the TOT-MEDICAID-PAID-AMT from the header record**Note: Missing values are converted to 0 before comparisonSTEP 7: Calculate the percentage for the measureDivide the count of header claims from STEP 6 by the count of header claims from STEP 4 | N/A |
03/27/2024 | 3.22.0 | ALL-35-002-2 | UPDATE | Specification | STEP 1: Active non-duplicate paid OT claims during report monthDefine 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 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: S-CHIP FFS and Encounter: Original and Replacement Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "A" or "C"2. ADJUSTMENT-IND = "0" or "4"STEP 3: Tooth-related procedure codesOf the claims that meet criteria from STEP 2, keep those with a PROCEDURE-CODE that matches one of the following criteria:1. PROCEDURE-CODE = “D1351” or “D2140” or “D2150” or “D2160” or “D2161” or “D2331” or “D2332” or “D2335” or “D2390” or “D2391” or “D2392” or “D2393” or “D2394” or “D3230” or “D3240” or “D3310” or “D3320” or “D3330”STEP 4: Missing tooth numberOf the claims that meet criteria from STEP 3, keep those with a missing TOOTH-NUMSTEP 5: Calculate percentageDivide the count of claim lines from STEP 4 by the count of claim lines from STEP 3 | STEP 1: Active non-duplicate paid OT claims during report monthDefine 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 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: S-CHIP FFS and Encounter: Original and Replacement Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "A" or "C"2. ADJUSTMENT-IND = "0" or "4"STEP 3: Tooth-related procedure codesOf the claims that meet criteria from STEP 2, keep those with a PROCEDURE-CODE that matches one of the following criteria:1. PROCEDURE-CODE = “D1351” or “D2140” or “D2150” or “D2160” or “D2161” or “D2330” or “D2331” or “D2332” or “D2335” or “D2390” or “D2391” or “D2392” or “D2393” or “D2394” or “D3230” or “D3240” or “D3310” or “D3320” or “D3330”STEP 4: Missing tooth numberOf the claims that meet criteria from STEP 3, keep those with a missing TOOTH-NUMSTEP 5: Calculate percentageDivide the count of claim lines from STEP 4 by the count of claim lines from STEP 3 |
03/27/2024 | 3.22.0 | ALL-35-001-1 | UPDATE | Specification | STEP 1: Active non-duplicate paid OT claims during report monthDefine 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 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 FFS and Encounter: Original and Replacement Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "1" or "3"2. ADJUSTMENT-IND = "0" or "4"STEP 3: Tooth-related procedure codesOf the claims that meet criteria from STEP 2, keep those with a PROCEDURE-CODE that matches one of the following criteria:1. PROCEDURE-CODE = “D1351” or “D2140” or “D2150” or “D2160” or “D2161” or “D2331” or “D2332” or “D2335” or “D2390” or “D2391” or “D2392” or “D2393” or “D2394” or “D3230” or “D3240” or “D3310” or “D3320” or “D3330”STEP 4: Missing tooth numberOf the claims that meet criteria from STEP 3, keep those with a missing TOOTH-NUMSTEP 5: Calculate percentageDivide the count of claim lines from STEP 4 by the count of claim lines from STEP 3 | STEP 1: Active non-duplicate paid OT claims during report monthDefine 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 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 FFS and Encounter: Original and Replacement Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "1" or "3"2. ADJUSTMENT-IND = "0" or "4"STEP 3: Tooth-related procedure codesOf the claims that meet criteria from STEP 2, keep those with a PROCEDURE-CODE that matches one of the following criteria:1. PROCEDURE-CODE = “D1351” or “D2140” or “D2150” or “D2160” or “D2161” or “D2330” or “D2331” or “D2332” or “D2335” or “D2390” or “D2391” or “D2392” or “D2393” or “D2394” or “D3230” or “D3240” or “D3310” or “D3320” or “D3330”STEP 4: Missing tooth numberOf the claims that meet criteria from STEP 3, keep those with a missing TOOTH-NUMSTEP 5: Calculate percentageDivide the count of claim lines from STEP 4 by the count of claim lines from STEP 3 |
02/02/2024 | 3.18.0 | RULE-7447 | UPDATE | Focus area | N/A | Unwinding |
06/19/2024 | 3.27.0 | ALL-27-002-2 | UPDATE | Longitudinal threshold | TBD | N/A |
06/19/2024 | 3.27.0 | ALL-27-001-1 | UPDATE | Longitudinal threshold | TBD | N/A |
03/27/2024 | 3.22.0 | RULE-2157 | UPDATE | Measure name | Ratio of errors for RULE-2157 in single reporting period | % of MSIS IDs with an alien restricted benefits code status (RESTRICTED-BENEFITS-CODE = 2) but CITIZENSHIP-IND = 1 |
03/27/2024 | 3.22.0 | RULE-2157 | UPDATE | Measure type | Ratio | Non-Claims Percentage |
03/27/2024 | 3.22.0 | RULE-2157 | UPDATE | Active | False | True |
03/27/2024 | 3.22.0 | RULE-2157 | UPDATE | Priority | N/A | High |
03/27/2024 | 3.22.0 | RULE-2157 | UPDATE | Category | N/A | Beneficiary demographics |
03/27/2024 | 3.22.0 | RULE-2157 | UPDATE | For ta comprehensive | No | TA- Inferential |
03/27/2024 | 3.22.0 | RULE-2157 | UPDATE | For ta inferential | No | Yes |
03/27/2024 | 3.22.0 | RULE-2157 | UPDATE | Ta min | 0 | |
03/27/2024 | 3.22.0 | RULE-2157 | UPDATE | Ta max | 0.01 | |
03/27/2024 | 3.22.0 | RULE-2157 | UPDATE | Threshold minimum | N/A | 0 |
03/27/2024 | 3.22.0 | RULE-2157 | UPDATE | Threshold maximum | N/A | 0.01 |
02/02/2024 | 3.18.0 | RULE-2135 | UPDATE | Focus area | N/A | Unwinding |
11/15/2023 | 3.16.0 | MIS-60-002-2 | UPDATE | Annotation | Numeric | N/A |
11/15/2023 | 3.16.0 | MIS-60-002-2 | UPDATE | Specification | STEP 1: Active non-duplicate OT claims during DQ report monthDefine the OT claims universe at the header level by importing both headers and lines that satisfy the following criteria:For Headers:1. Reporting Period from 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 Service Tracking, Non-void claimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "4" or "D"2. ADJUSTMENT-IND does not equal "1"STEP 3: Missing data elementOf the claims that meet the criteria from STEP 2, select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 4: Calculate percentageDivide the count of claims from STEP 3 by the count of claims from STEP 2 | N/A |
11/15/2023 | 3.16.0 | MIS-60-001-1 | UPDATE | Annotation | Numeric | N/A |
11/15/2023 | 3.16.0 | MIS-60-001-1 | UPDATE | Specification | STEP 1: Active non-duplicate OT claims during DQ report monthDefine the OT claims universe at the header level by importing both headers and lines that satisfy the following criteria:For Headers:1. Reporting Period from 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 Service Tracking, Non-void claimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "4" or "D"2. ADJUSTMENT-IND does not equal "1"STEP 3: Missing data elementOf the claims that meet the criteria from STEP 2, select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 4: Calculate percentageDivide the count of claims from STEP 3 by the count of claims from STEP 2 | N/A |
11/15/2023 | 3.16.0 | MIS-59-002-2 | UPDATE | Annotation | Numeric | N/A |
11/15/2023 | 3.16.0 | MIS-59-002-2 | UPDATE | Specification | STEP 1: Active non-duplicate OT claims during DQ report monthDefine the OT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 2: Medicaid and S-CHIP Service Tracking, Non-void claimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "4" or "D"2. ADJUSTMENT-IND does not equal "1"STEP 3: Missing data elementOf the claims that meet the criteria from STEP 2, select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 4: Calculate percentageDivide the count of claims from STEP 3 by the count of claims from STEP 2 | N/A |
11/15/2023 | 3.16.0 | MIS-59-001-1 | UPDATE | Annotation | Numeric | N/A |
11/15/2023 | 3.16.0 | MIS-59-001-1 | UPDATE | Specification | STEP 1: Active non-duplicate OT claims during DQ report monthDefine the OT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 2: Medicaid and S-CHIP Service Tracking, Non-void claimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "4" or "D"2. ADJUSTMENT-IND does not equal "1"STEP 3: Missing data elementOf the claims that meet the criteria from STEP 2, select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 4: Calculate percentageDivide the count of claims from STEP 3 by the count of claims from STEP 2 | N/A |
11/15/2023 | 3.16.0 | MIS-58-002-2 | UPDATE | Annotation | Numeric | N/A |
11/15/2023 | 3.16.0 | MIS-58-002-2 | UPDATE | Specification | STEP 1: Active non-duplicate LT claims during DQ report monthDefine the LT claims universe at the header level by importing both headers and lines that satisfy the following criteria:For Headers:1. Reporting Period from 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 Service Tracking, Non-void claimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "4" or "D"2. ADJUSTMENT-IND does not equal "1"STEP 3: Missing data elementOf the claims that meet the criteria from STEP 2, select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 4: Calculate percentageDivide the count of claims from STEP 3 by the count of claims from STEP 2 | N/A |
11/15/2023 | 3.16.0 | MIS-58-001-1 | UPDATE | Annotation | Numeric | N/A |
11/15/2023 | 3.16.0 | MIS-58-001-1 | UPDATE | Specification | STEP 1: Active non-duplicate LT claims during DQ report monthDefine the LT claims universe at the header level by importing both headers and lines that satisfy the following criteria:For Headers:1. Reporting Period from 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 Service Tracking, Non-void claimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "4" or "D"2. ADJUSTMENT-IND does not equal "1"STEP 3: Missing data elementOf the claims that meet the criteria from STEP 2, select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 4: Calculate percentageDivide the count of claims from STEP 3 by the count of claims from STEP 2 | N/A |
11/15/2023 | 3.16.0 | MIS-57-002-2 | UPDATE | Annotation | Numeric | N/A |
11/15/2023 | 3.16.0 | MIS-57-002-2 | UPDATE | Specification | STEP 1: Active non-duplicate LT claims during DQ report monthDefine the LT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 2: Medicaid and S-CHIP Service Tracking, Non-void claimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "4" or "D"2. ADJUSTMENT-IND does not equal "1"STEP 3: Missing data elementOf the claims that meet the criteria from STEP 2, select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 4: Calculate percentageDivide the count of claims from STEP 3 by the count of claims from STEP 2 | N/A |
11/15/2023 | 3.16.0 | MIS-57-001-1 | UPDATE | Annotation | Numeric | N/A |
11/15/2023 | 3.16.0 | MIS-57-001-1 | UPDATE | Specification | STEP 1: Active non-duplicate LT claims during DQ report monthDefine the LT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 2: Medicaid and S-CHIP Service Tracking, Non-void claimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "4" or "D"2. ADJUSTMENT-IND does not equal "1"STEP 3: Missing data elementOf the claims that meet the criteria from STEP 2, select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements: 1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 4: Calculate percentageDivide the count of claims from STEP 3 by the count of claims from STEP 2 | N/A |
11/15/2023 | 3.16.0 | MIS-55-001-1 | UPDATE | Annotation | Numeric | N/A |
11/15/2023 | 3.16.0 | MIS-55-001-1 | UPDATE | Specification | STEP 1: Active non-duplicate IP claims during DQ report monthDefine the IP claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 2: Medicaid and S-CHIP Service Tracking, Non-void claimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "4" or "D"2. ADJUSTMENT-IND does not equal "1"STEP 3: Missing data elementOf the claims that meet the criteria from STEP 2, select those whereFor alphanumeric data elements:1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9For numeric data elements:1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 4: Calculate percentageDivide the count of claims from STEP 3 by the count of claim from STEP 2 | N/A |
02/02/2024 | 3.18.0 | MCR-64-004-4 | UPDATE | Focus area | Managed care | N/A |
02/02/2024 | 3.18.0 | MCR-64-003-3 | UPDATE | Focus area | Managed care | N/A |
02/02/2024 | 3.18.0 | MCR-64-002-2 | UPDATE | Focus area | Managed care | N/A |
02/02/2024 | 3.18.0 | MCR-64-001-1 | UPDATE | Focus area | Managed care | N/A |
02/02/2024 | 3.18.0 | MCR-63-004-4 | UPDATE | Focus area | Managed care | N/A |
02/02/2024 | 3.18.0 | MCR-63-003-3 | UPDATE | Focus area | Managed care | N/A |
02/02/2024 | 3.18.0 | MCR-63-002-2 | UPDATE | Focus area | Managed care | N/A |
02/02/2024 | 3.18.0 | MCR-63-001-1 | UPDATE | Focus area | Managed care | N/A |
03/27/2024 | 3.22.0 | EL-6-034-34 | UPDATE | Priority | High | N/A |
03/27/2024 | 3.22.0 | EL-6-034-34 | UPDATE | Category | Beneficiary demographics | N/A |
03/27/2024 | 3.22.0 | EL-6-034-34 | UPDATE | For ta comprehensive | TA- Inferential | No |
03/27/2024 | 3.22.0 | EL-6-034-34 | UPDATE | For ta inferential | Yes | No |
03/27/2024 | 3.22.0 | EL-6-034-34 | UPDATE | Ta min | 0 | |
03/27/2024 | 3.22.0 | EL-6-034-34 | UPDATE | Ta max | 0.01 | |
03/27/2024 | 3.22.0 | EL-6-034-34 | UPDATE | Annotation | Calculate the percentage of eligibles with an alien restricted benefits code who have a U.S. citizenship indicator | N/A |
03/27/2024 | 3.22.0 | EL-6-034-34 | UPDATE | Specification | STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Eligibility determinants on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 1, join to segment ELIGIBILITY-DETERMINANTS-ELG00005 by keeping records that satisfy the following criteria:1. PRIMARY-ELIGIBILITY-GROUP-IND = 12a. ELIGIBILITY-DETERMINANT-EFF-DATE <= last day of the DQ report month3a. ELIGIBILITY-DETERMINANT-END-DATE >= last day of the DQ report month OR missingOR2b. ELIGIBILITY-DETERMINANT-EFF-DATE is missing3b. ELIGIBILITY-DETERMINANT-END-DATE is missingSTEP 3: Alien restricted benefits codeOf the MSIS IDs that meet the criteria from STEP 2, further refine the population by keeping MSIS IDs where:1. RESTRICTED-BENEFITS-CODE equals “2” STEP 4: Variable demographics on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 3, join to segment VARIABLE-DEMOGRAPHIC-ELG00003 by keeping records that satisfy the following criteria:1a. VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE <= last day of the DQ report month2a. VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE >= last day of the DQ report month OR missingOR1b. VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE is missing2b. VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE is missingSTEP 5: Citizenship status indicates a U.S. CitizenOf the MSIS IDs that meet the criteria from STEP 4, further refine the population by keeping MSIS IDs where:1. CITIZENSHIP-IND equals "1"STEP 6: Calculate percentageDivide the count from STEP 5 by the count from STEP 3 | N/A |
03/27/2024 | 3.22.0 | EL-6-033-33 | UPDATE | Priority | High | N/A |
03/27/2024 | 3.22.0 | EL-6-033-33 | UPDATE | Category | Beneficiary demographics | N/A |
03/27/2024 | 3.22.0 | EL-6-033-33 | UPDATE | For ta comprehensive | TA- Inferential | No |
03/27/2024 | 3.22.0 | EL-6-033-33 | UPDATE | For ta inferential | Yes | No |
03/27/2024 | 3.22.0 | EL-6-033-33 | UPDATE | Ta min | 0 | |
03/27/2024 | 3.22.0 | EL-6-033-33 | UPDATE | Ta max | 0.01 | |
03/27/2024 | 3.22.0 | EL-6-033-33 | UPDATE | Annotation | Calculate the percentage of eligibles with a restricted benefits code status designating alien status whose immigration is not a qualified alien status | N/A |
03/27/2024 | 3.22.0 | EL-6-033-33 | UPDATE | Specification | STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Eligibility determinants on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 1, join to segment ELIGIBILITY-DETERMINANTS-ELG00005 by keeping records that satisfy the following criteria:1. PRIMARY-ELIGIBILITY-GROUP-IND = 12a. ELIGIBILITY-DETERMINANT-EFF-DATE <= last day of the DQ report month3a. ELIGIBILITY-DETERMINANT-END-DATE >= last day of the DQ report month OR missingOR2b. ELIGIBILITY-DETERMINANT-EFF-DATE is missing3b. ELIGIBILITY-DETERMINANT-END-DATE is missingSTEP 3: Alien restricted benefits codeOf the MSIS IDs that meet the criteria from STEP 2, further refine the population by keeping MSIS IDs where:1. RESTRICTED-BENEFITS-CODE equals “2” STEP 4: Variable demographics on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 3, join to segment VARIABLE-DEMOGRAPHIC-ELG00003 by keeping records that satisfy the following criteria:1a. VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE <= last day of the DQ report month2a. VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE >= last day of the DQ report month OR missingOR1b. VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE is missing2b. VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE is missingSTEP 5: Immigration status is not a qualified alien statusOf the MSIS IDs that meet the criteria from STEP 4, further refine the population by keeping MSIS IDs where:1. IMMIGRATION-STATUS does not equal "1" or "2" or "3"STEP 6: Calculate percentageDivide the count from STEP 5 by the count from STEP 3 | N/A |
03/27/2024 | 3.22.0 | EL-1-015_2-26 | UPDATE | Priority | High | N/A |
03/27/2024 | 3.22.0 | EL-1-015_2-26 | UPDATE | Category | Beneficiary demographics | N/A |
03/27/2024 | 3.22.0 | EL-1-015_2-26 | UPDATE | For ta comprehensive | TA- Inferential | No |
03/27/2024 | 3.22.0 | EL-1-015_2-26 | UPDATE | For ta inferential | Yes | No |
03/27/2024 | 3.22.0 | EL-1-015_2-26 | UPDATE | Ta min | 0 | |
03/27/2024 | 3.22.0 | EL-1-015_2-26 | UPDATE | Ta max | 0.01 | |
03/27/2024 | 3.22.0 | EL-1-015_2-26 | UPDATE | Annotation | Calculate the percentage of eligibles with a U.S. citizenship indicator whose immigration status does not correspond to a citizen | N/A |
03/27/2024 | 3.22.0 | EL-1-015_2-26 | UPDATE | Specification | STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Variable demographics on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 1, join to segment VARIABLE-DEMOGRAPHIC-ELG00003 by keeping records that satisfy the following criteria:1a. VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE <= last day of the DQ report month2a. VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE >= last day of the DQ report month OR missingOR1b. VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE is missing2b. VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE is missingSTEP 3: U.S. citizenOf the MSIS IDs that meet the criteria from STEP 2, further refine the population by keeping MSIS IDs where:1. CITIZENSHIP-IND = "1"STEP 4: Non U.S. citizen immigration statusOf the MSIS IDs that meet the criteria from STEP 2, further refine the population by keeping MSIS IDs where:1. IMMIGRATION-STATUS does not equal "8"OR2. IMMIGRATION-STATUS is missingSTEP 5: Calculate percentageDivide the count of unique MSIS IDs from STEP 4 by the count of unique MSIS IDs from STEP 3 | N/A |
03/27/2024 | 3.22.0 | EL-1-015_1-25 | UPDATE | Priority | High | N/A |
03/27/2024 | 3.22.0 | EL-1-015_1-25 | UPDATE | Category | Beneficiary demographics | N/A |
03/27/2024 | 3.22.0 | EL-1-015_1-25 | UPDATE | For ta comprehensive | TA- Inferential | No |
03/27/2024 | 3.22.0 | EL-1-015_1-25 | UPDATE | For ta inferential | Yes | No |
03/27/2024 | 3.22.0 | EL-1-015_1-25 | UPDATE | Ta min | 0 | |
03/27/2024 | 3.22.0 | EL-1-015_1-25 | UPDATE | Ta max | 0.01 | |
03/27/2024 | 3.22.0 | EL-1-015_1-25 | UPDATE | Annotation | Calculate the percentage of eligibles with a citizen immigration status whose citizenship indicator does not indicate they are citizens | N/A |
03/27/2024 | 3.22.0 | EL-1-015_1-25 | UPDATE | Specification | STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Variable demographics on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 1, join to segment VARIABLE-DEMOGRAPHIC-ELG00003 by keeping records that satisfy the following criteria:1a. VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE <= last day of the DQ report month2a. VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE >= last day of the DQ report month OR missingOR1b. VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE is missing2b. VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE is missingSTEP 3: U.S. citizen immigration statusOf the MSIS IDs that meet the criteria from STEP 2, further refine the population by keeping MSIS IDs where:1. IMMIGRATION-STATUS = "8"STEP 4: Citizenship indicator not US CitizenOf the MSIS IDs that meet the criteria from STEP 3, restrict to those where:1. CITIZENSHIP-IND does not equal "1"OR2. CITIZENSHIP-IND is missingSTEP 5: Calculate percentageDivide the count of unique MSIS IDs from STEP 4 by the count of unique MSIS IDs from STEP 3 | N/A |
02/02/2024 | 3.18.0 | ALL-15-006-6 | UPDATE | Priority | High | N/A |
02/02/2024 | 3.18.0 | ALL-15-006-6 | UPDATE | Category | Utilization | N/A |
02/02/2024 | 3.18.0 | ALL-15-006-6 | UPDATE | For ta comprehensive | TA- Inferential | No |
02/02/2024 | 3.18.0 | ALL-15-006-6 | UPDATE | For ta inferential | Yes | No |
02/02/2024 | 3.18.0 | ALL-15-006-6 | UPDATE | Ta min | 0 | |
02/02/2024 | 3.18.0 | ALL-15-006-6 | UPDATE | Ta max | 0.01 | |
02/02/2024 | 3.18.0 | ALL-15-005-5 | UPDATE | Priority | High | N/A |
02/02/2024 | 3.18.0 | ALL-15-005-5 | UPDATE | Category | Utilization | N/A |
02/02/2024 | 3.18.0 | ALL-15-005-5 | UPDATE | For ta comprehensive | TA- Inferential | No |
02/02/2024 | 3.18.0 | ALL-15-005-5 | UPDATE | For ta inferential | Yes | No |
02/02/2024 | 3.18.0 | ALL-15-005-5 | UPDATE | Ta min | 0 | |
02/02/2024 | 3.18.0 | ALL-15-005-5 | UPDATE | Ta max | 0.001 | |
02/02/2024 | 3.18.0 | ALL-15-004-4 | UPDATE | Priority | High | N/A |
02/02/2024 | 3.18.0 | ALL-15-004-4 | UPDATE | Category | Utilization | N/A |
02/02/2024 | 3.18.0 | ALL-15-004-4 | UPDATE | For ta comprehensive | TA- Inferential | No |
02/02/2024 | 3.18.0 | ALL-15-004-4 | UPDATE | For ta inferential | Yes | No |
02/02/2024 | 3.18.0 | ALL-15-004-4 | UPDATE | Ta min | 0 | |
02/02/2024 | 3.18.0 | ALL-15-004-4 | UPDATE | Ta max | 0.001 | |
02/02/2024 | 3.18.0 | ALL-15-003-3 | UPDATE | Priority | High | N/A |
02/02/2024 | 3.18.0 | ALL-15-003-3 | UPDATE | Category | Utilization | N/A |
02/02/2024 | 3.18.0 | ALL-15-003-3 | UPDATE | For ta comprehensive | TA- Inferential | No |
02/02/2024 | 3.18.0 | ALL-15-003-3 | UPDATE | For ta inferential | Yes | No |
02/02/2024 | 3.18.0 | ALL-15-003-3 | UPDATE | Ta min | 0 | |
02/02/2024 | 3.18.0 | ALL-15-003-3 | UPDATE | Ta max | 0.15 | |
06/19/2024 | 3.27.0 | MCR-61-008-8 | UPDATE | Priority | High | N/A |
06/19/2024 | 3.27.0 | MCR-61-008-8 | UPDATE | Category | Provider information | N/A |
06/19/2024 | 3.27.0 | MCR-61-008-8 | UPDATE | For ta comprehensive | TA- Inferential | No |
06/19/2024 | 3.27.0 | MCR-61-008-8 | UPDATE | For ta inferential | Yes | No |
06/19/2024 | 3.27.0 | MCR-61-008-8 | UPDATE | Ta min | 0 | |
06/19/2024 | 3.27.0 | MCR-61-008-8 | UPDATE | Ta max | 0.01 | |
06/19/2024 | 3.27.0 | MCR-61-008-8 | UPDATE | Annotation | Calculate the percentage S-CHIP Encounter: original and adjustment, paid RX claims with an invalid billing provider NPI number | N/A |
06/19/2024 | 3.27.0 | MCR-61-008-8 | UPDATE | Specification | STEP 1: Active non-duplicate RX records during DQ report monthDefine the RX records universe at the header level that satisfy the following criteria: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.STEP 2: S-CHIP Encounter: Original and Adjustment, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "C"STEP 3: Non-missing billing provider NPI number Of the claims that meet the criteria from STEP 2, restrict to claims with a non-missing BILLING-PROV-NPI-NUMSTEP 4: Calculate Luhn check digitOf the claims that meet the criteria from STEP 3, follow the steps below to calculate the Luhn check digit: 1. Ensure that BILLING-PROV-NPI-NUM only contains digits 0-9.2. Ensure that BILLING-PROV-NPI-NUM has length 10.3. Using BILLING-PROV-NPI-NUM, double the digits in slots 1, 3, 5, 7, and 9. 4. If the doubling of the digits results in a number that is greater than or equal to 10, split the digits. For example, 14 becomes 1 and 4. 5. Add the digits from step 4 to the digits in slots 2, 4, 6, and 8.6. Add 24 to the sum from step 5. 7. Round the result from step 6 up to the nearest 10s place.8. Subtract the result from step 6 from the result in step 7.Example: Billing Provider NPI Num = 12345678931. Passes check2. Passes check3. Double odd-slotted digits: 2 6 10 14 18 4. Split digits 10 and over: 2 6 1 0 1 4 1 85. Add digits from above and even-slotted digits: 2 + 6 + 1 + 0 + 1 + 4 + 1 + 8 + 2 + 4 + 6 + 8 = 43. 6. Add 24: 24 + 43 = 67 7. Round up: 67 rounds up to 708. Subtract: 70 - 67 = 3STEP 5: Invalid billing provider NPI numberOf the claims that meet the criteria from STEP 4, keep those that meet the following criteria: 1a. Luhn check digit from STEP 4 does not equal 10th digit of BILLING-PROV-NPI-NUMORBILLING-PROV-NPI-NUM does not begin with “1”STEP 6: Calculate percentDivide the count from STEP 5 from STEP 3 | N/A |
06/19/2024 | 3.27.0 | MCR-61-008-8 | UPDATE | Focus area | Managed care | N/A |
06/19/2024 | 3.27.0 | MCR-61-007-7 | UPDATE | Priority | High | N/A |
06/19/2024 | 3.27.0 | MCR-61-007-7 | UPDATE | Category | Provider information | N/A |
06/19/2024 | 3.27.0 | MCR-61-007-7 | UPDATE | For ta comprehensive | TA- Inferential | No |
06/19/2024 | 3.27.0 | MCR-61-007-7 | UPDATE | For ta inferential | Yes | No |
06/19/2024 | 3.27.0 | MCR-61-007-7 | UPDATE | Ta min | 0 | |
06/19/2024 | 3.27.0 | MCR-61-007-7 | UPDATE | Ta max | 0.01 | |
06/19/2024 | 3.27.0 | MCR-61-007-7 | UPDATE | Annotation | Calculate the percentage S-CHIP Encounter: original and adjustment, paid OT claims with an invalid billing provider NPI number | N/A |
06/19/2024 | 3.27.0 | MCR-61-007-7 | UPDATE | Specification | STEP 1: Active non-duplicate OT records during DQ report monthDefine the OT records universe at the header level that satisfy the following criteria: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.STEP 2: S-CHIP Encounter: Original and Adjustment, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "C"STEP 3: Non-missing billing provider NPI numberOf the claims that meet the criteria from STEP 2, restrict to claims with a non-missing BILLING-PROV-NPI-NUMSTEP 4: Calculate Luhn check digitOf the claims that meet the criteria from STEP 3, follow the steps below to calculate the Luhn check digit: 1. Ensure that BILLING-PROV-NPI-NUM only contains digits 0-9.2. Ensure that BILLING-PROV-NPI-NUM has length 10.3. Using BILLING-PROV-NPI-NUM, double the digits in slots 1, 3, 5, 7, and 9. 4. If the doubling of the digits results in a number that is greater than or equal to 10, split the digits. For example, 14 becomes 1 and 4. 5. Add the digits from step 4 to the digits in slots 2, 4, 6, and 8.6. Add 24 to the sum from step 5. 7. Round the result from step 6 up to the nearest 10s place.8. Subtract the result from step 6 from the result in step 7.Example: Billing Provider NPI Num = 12345678931. Passes check2. Passes check3. Double odd-slotted digits: 2 6 10 14 18 4. Split digits 10 and over: 2 6 1 0 1 4 1 85. Add digits from above and even-slotted digits: 2 + 6 + 1 + 0 + 1 + 4 + 1 + 8 + 2 + 4 + 6 + 8 = 43. 6. Add 24: 24 + 43 = 67 7. Round up: 67 rounds up to 708. Subtract: 70 - 67 = 3STEP 5: Invalid billing provider NPI numberOf the claims that meet the criteria from STEP 4, keep those that meet the following criteria: 1a. Luhn check digit from STEP 4 does not equal 10th digit of BILLING-PROV-NPI-NUMOR1b. BILLING-PROV-NPI-NUM does not begin with “1”STEP 6: Calculate percentDivide the count from STEP 5 from STEP 3 | N/A |
06/19/2024 | 3.27.0 | MCR-61-007-7 | UPDATE | Focus area | Managed care | N/A |
06/19/2024 | 3.27.0 | MCR-61-006-6 | UPDATE | Priority | High | N/A |
06/19/2024 | 3.27.0 | MCR-61-006-6 | UPDATE | Category | Provider information | N/A |
06/19/2024 | 3.27.0 | MCR-61-006-6 | UPDATE | For ta comprehensive | TA- Inferential | No |
06/19/2024 | 3.27.0 | MCR-61-006-6 | UPDATE | For ta inferential | Yes | No |
06/19/2024 | 3.27.0 | MCR-61-006-6 | UPDATE | Ta min | 0 | |
06/19/2024 | 3.27.0 | MCR-61-006-6 | UPDATE | Ta max | 0.01 | |
06/19/2024 | 3.27.0 | MCR-61-006-6 | UPDATE | Annotation | Calculate the percentage S-CHIP Encounter: original and adjustment, paid LT claims with an invalid billing provider NPI number | N/A |
06/19/2024 | 3.27.0 | MCR-61-006-6 | UPDATE | Specification | STEP 1: Active non-duplicate LT records during DQ report monthDefine the LT records universe at the header level that satisfy the following criteria: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.STEP 2: S-CHIP Encounter: Original and Adjustment, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "C"STEP 3: Non-missing billing provider NPI numberOf the claims that meet the criteria from STEP 2, restrict to claims with a non-missing BILLING-PROV-NPI-NUMSTEP 4: Calculate Luhn check digitOf the claims that meet the criteria from STEP 3, follow the steps below to calculate the Luhn check digit: 1. Ensure that BILLING-PROV-NPI-NUM only contains digits 0-9.2. Ensure that BILLING-PROV-NPI-NUM has length 10.3. Using BILLING-PROV-NPI-NUM, double the digits in slots 1, 3, 5, 7, and 9. 4. If the doubling of the digits results in a number that is greater than or equal to 10, split the digits. For example, 14 becomes 1 and 4. 5. Add the digits from step 4 to the digits in slots 2, 4, 6, and 8.6. Add 24 to the sum from step 5. 7. Round the result from step 6 up to the nearest 10s place.8. Subtract the result from step 6 from the result in step 7.Example: Billing Provider NPI Num = 12345678931. Passes check2. Passes check3. Double odd-slotted digits: 2 6 10 14 18 4. Split digits 10 and over: 2 6 1 0 1 4 1 85. Add digits from above and even-slotted digits: 2 + 6 + 1 + 0 + 1 + 4 + 1 + 8 + 2 + 4 + 6 + 8 = 43. 6. Add 24: 24 + 43 = 67 7. Round up: 67 rounds up to 708. Subtract: 70 - 67 = 3STEP 5: Invalid billing provider NPI numberOf the claims that meet the criteria from STEP 4, keep those that meet the following criteria: 1a. Luhn check digit from STEP 4 does not equal 10th digit of BILLING-PROV-NPI-NUMOR1b. BILLING-PROV-NPI-NUM does not begin with “1”STEP 6: Calculate percentDivide the count from STEP 5 from STEP 3 | N/A |
06/19/2024 | 3.27.0 | MCR-61-006-6 | UPDATE | Focus area | Managed care | N/A |
06/19/2024 | 3.27.0 | MCR-61-005-5 | UPDATE | Priority | High | N/A |
06/19/2024 | 3.27.0 | MCR-61-005-5 | UPDATE | Category | Provider information | N/A |
06/19/2024 | 3.27.0 | MCR-61-005-5 | UPDATE | For ta comprehensive | TA- Inferential | No |
06/19/2024 | 3.27.0 | MCR-61-005-5 | UPDATE | For ta inferential | Yes | No |
06/19/2024 | 3.27.0 | MCR-61-005-5 | UPDATE | Ta min | 0 | |
06/19/2024 | 3.27.0 | MCR-61-005-5 | UPDATE | Ta max | 0.01 | |
06/19/2024 | 3.27.0 | MCR-61-005-5 | UPDATE | Annotation | Calculate the percentage S-CHIP Encounter: original and adjustment, paid IP claims with an invalid billing provider NPI number | N/A |
06/19/2024 | 3.27.0 | MCR-61-005-5 | UPDATE | Specification | STEP 1: Active non-duplicate paid IP claims during report monthDefine the IP claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 2: S-CHIP Encounter: Original and Adjustment, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "C"STEP 3: Non-missing billing provider NPI numberOf the claims that meet the criteria from STEP 2, restrict to claims with a non-missing BILLING-PROV-NPI-NUMSTEP 4: Calculate Luhn check digitOf the claims that meet the criteria from STEP 3, follow the steps below to calculate the Luhn check digit: 1. Ensure that BILLING-PROV-NPI-NUM only contains digits 0-9.2. Ensure that BILLING-PROV-NPI-NUM has length 10.3. Using BILLING-PROV-NPI-NUM, double the digits in slots 1, 3, 5, 7, and 9. 4. If the doubling of the digits results in a number that is greater than or equal to 10, split the digits. For example, 14 becomes 1 and 4. 5. Add the digits from step 4 to the digits in slots 2, 4, 6, and 8.6. Add 24 to the sum from step 5. 7. Round the result from step 6 up to the nearest 10s place.8. Subtract the result from step 6 from the result in step 7.Example: Billing Provider NPI Num = 12345678931. Passes check2. Passes check3. Double odd-slotted digits: 2 6 10 14 18 4. Split digits 10 and over: 2 6 1 0 1 4 1 85. Add digits from above and even-slotted digits: 2 + 6 + 1 + 0 + 1 + 4 + 1 + 8 + 2 + 4 + 6 + 8 = 43. 6. Add 24: 24 + 43 = 67 7. Round up: 67 rounds up to 708. Subtract: 70 - 67 = 3STEP 5: Invalid billing provider NPI numberOf the claims that meet the criteria from STEP 4, keep those that meet the following criteria: 1a. Luhn check digit from STEP 4 does not equal 10th digit of BILLING-PROV-NPI-NUMOR1b. BILLING-PROV-NPI-NUM does not begin with “1”STEP 6: Calculate percentDivide the count from STEP 5 from STEP 3 | N/A |
06/19/2024 | 3.27.0 | MCR-61-005-5 | UPDATE | Focus area | Managed care | N/A |
06/19/2024 | 3.27.0 | MCR-61-003-3 | UPDATE | Priority | High | N/A |
06/19/2024 | 3.27.0 | MCR-61-003-3 | UPDATE | Category | Provider information | N/A |
06/19/2024 | 3.27.0 | MCR-61-003-3 | UPDATE | For ta comprehensive | TA- Inferential | No |
06/19/2024 | 3.27.0 | MCR-61-003-3 | UPDATE | For ta inferential | Yes | No |
06/19/2024 | 3.27.0 | MCR-61-003-3 | UPDATE | Ta min | 0 | |
06/19/2024 | 3.27.0 | MCR-61-003-3 | UPDATE | Ta max | 0.05 | |
06/19/2024 | 3.27.0 | MCR-61-003-3 | UPDATE | Annotation | Calculate the percentage of S-CHIP Encounter: original and adjustment, paid OT claims with a non-missing billing provider taxonomy that is equal to an invalid value | N/A |
06/19/2024 | 3.27.0 | MCR-61-003-3 | UPDATE | Specification | STEP 1: Active non-duplicate paid OT claims during report monthDefine the OT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 2: S-CHIP Encounter: Original and Adjustment, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "C"STEP 3: Non-missing billing provider taxonomyOf the claims that meet the criteria from STEP 2, restrict to claims with a non-missing BILLING-PROV-TAXONOMYSTEP 4: Count of claims with an invalid billing provider taxonomyOf the claims that meet the criteria from STEP 3, count claims where BILLING-PROV-TAXONOMY is not equal to a valid valueSTEP 5: Calculate percentDivide the count from STEP 4 by the count from STEP 3 | N/A |
06/19/2024 | 3.27.0 | MCR-61-003-3 | UPDATE | Focus area | Managed care | N/A |
06/19/2024 | 3.27.0 | MCR-61-002-2 | UPDATE | Priority | High | N/A |
06/19/2024 | 3.27.0 | MCR-61-002-2 | UPDATE | Category | Provider information | N/A |
06/19/2024 | 3.27.0 | MCR-61-002-2 | UPDATE | For ta comprehensive | TA- Inferential | No |
06/19/2024 | 3.27.0 | MCR-61-002-2 | UPDATE | For ta inferential | Yes | No |
06/19/2024 | 3.27.0 | MCR-61-002-2 | UPDATE | Ta min | 0 | |
06/19/2024 | 3.27.0 | MCR-61-002-2 | UPDATE | Ta max | 0.05 | |
06/19/2024 | 3.27.0 | MCR-61-002-2 | UPDATE | Annotation | Calculate the percentage of S-CHIP Encounter: original and adjustment, paid LT claims with a non-missing billing provider taxonomy that is equal to an invalid value | N/A |
06/19/2024 | 3.27.0 | MCR-61-002-2 | UPDATE | Specification | STEP 1: Active non-duplicate paid LT claims during report monthDefine the LT claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 2: S-CHIP Encounter: Original and Adjustment, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "C"STEP 3: Non-missing billing provider taxonomyOf the claims that meet the criteria from STEP 2, restrict to claims with a non-missing BILLING-PROV-TAXONOMYSTEP 4: Count of claims with an invalid billing provider taxonomyOf the claims that meet the criteria from STEP 3, count claims where BILLING-PROV-TAXONOMY is not equal to a valid valueSTEP 5: Calculate percentDivide the count from STEP 4 by the count from STEP 3 | N/A |
06/19/2024 | 3.27.0 | MCR-61-002-2 | UPDATE | Focus area | Managed care | N/A |
06/19/2024 | 3.27.0 | MCR-61-001-1 | UPDATE | Priority | High | N/A |
06/19/2024 | 3.27.0 | MCR-61-001-1 | UPDATE | Category | Provider information | N/A |
06/19/2024 | 3.27.0 | MCR-61-001-1 | UPDATE | For ta comprehensive | TA- Inferential | No |
06/19/2024 | 3.27.0 | MCR-61-001-1 | UPDATE | For ta inferential | Yes | No |
06/19/2024 | 3.27.0 | MCR-61-001-1 | UPDATE | Ta min | 0 | |
06/19/2024 | 3.27.0 | MCR-61-001-1 | UPDATE | Ta max | 0.05 | |
06/19/2024 | 3.27.0 | MCR-61-001-1 | UPDATE | Annotation | Calculate the percentage of S-CHIP Encounter: original and adjustment, paid IP claims with a non-missing billing provider taxonomy that is equal to an invalid value | N/A |
06/19/2024 | 3.27.0 | MCR-61-001-1 | UPDATE | Specification | STEP 1: Active non-duplicate paid IP claims during report monthDefine the IP claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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.STEP 2: S-CHIP Encounter: Original and Adjustment, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "C"STEP 3: Non-missing billing provider taxonomyOf the claims that meet the criteria from STEP 2, restrict to claims with a non-missing BILLING-PROV-TAXONOMYSTEP 4: Count of claims with an invalid billing provider taxonomyOf the claims that meet the criteria from STEP 3, count claims where BILLING-PROV-TAXONOMY is not equal to a valid valueSTEP 5: Calculate percentDivide the count from STEP 4 by the count from STEP 3 | N/A |
06/19/2024 | 3.27.0 | MCR-61-001-1 | UPDATE | Focus area | Managed care | N/A |
06/19/2024 | 3.27.0 | MCR-60-008-8 | UPDATE | Priority | High | N/A |
06/19/2024 | 3.27.0 | MCR-60-008-8 | UPDATE | Category | Provider information | N/A |
06/19/2024 | 3.27.0 | MCR-60-008-8 | UPDATE | For ta comprehensive | TA- Inferential | No |
06/19/2024 | 3.27.0 | MCR-60-008-8 | UPDATE | For ta inferential | Yes | No |
06/19/2024 | 3.27.0 | MCR-60-008-8 | UPDATE | Ta min | 0 | |
06/19/2024 | 3.27.0 | MCR-60-008-8 | UPDATE | Ta max | 0.01 | |
06/19/2024 | 3.27.0 | MCR-60-008-8 | UPDATE | Annotation | Calculate the percentage Medicaid Encounter: original and adjustment, paid RX claims with an invalid billing provider NPI number | N/A |
06/19/2024 | 3.27.0 |