| 11/07/2025 |
3.40.0 |
ELG.003.038 |
UPDATE |
Definition |
A code indicating the federal poverty level range in which the family income falls.
If the beneficiary's income was assessed using multiple methodologies (MAGI and Non-MAGI), report the income that applies to their primary eligibility group.
A beneficiary’s income is applicable unless it is not required by the eligibility group for which they were determined eligible. For example, the eligibility groups for children with adoption assistance, foster care, or guardianship care under title IV-E and optional eligibility for individuals needing treatment for breast or cervical cancer do not have a Medicaid income test. Additionally, for individuals receiving SSI, states with section 1634 agreements with the Social Security Administration (SSA) and states that use SSI financial methodologies for Medicaid determinations do not conduct separate Medicaid financial eligibility for this group. |
A code indicating the federal poverty level range in which the family income falls.
If the beneficiary's income was assessed using multiple methodologies (MAGI and Non-MAGI), report the income that applies to their primary eligibility group.
A beneficiary's income is applicable unless it is not required by the eligibility group for which they were determined eligible. For example, the eligibility groups for children with adoption assistance, foster care, or guardianship care under title IV-E and optional eligibility for individuals needing treatment for breast or cervical cancer do not have a Medicaid income test. Additionally, for individuals receiving SSI, states with section 1634 agreements with the Social Security Administration (SSA) and states that use SSI financial methodologies for Medicaid determinations do not conduct separate Medicaid financial eligibility for this group. |
| 11/07/2025 |
3.40.0 |
ELG.003.034 |
UPDATE |
Definition |
A code to classify eligible individual's marital/domestic-relationship status. This element should be reported by the state when the information is material to eligibility (i.e., institutionalization).
Because there is no specific statutory or regulatory basis for defining marital status codes, they are being defined in a way that is as flexible for states and data users as possible. States can report at whatever level of granularity is available to them in their system and a data user can choose to use them as-is or roll the values up in broader categories depending on whichever approach best meets their needs. CMS periodically reviews the values reported to MARITAL-STATUS-OTHER-EXPLANATION to determine if states are appropriately using it only when there is no existing MARITAL-STATUS value that reflects the state’s marital status description for an individual AND to determine whether it is necessary to add additional T-MSIS MARITAL-STATUS values to reflect commonly used state martial status descriptions for which there is no existing T-MSIS MARITAL-STATUS value. |
A code to classify eligible individual's marital/domestic-relationship status. This element should be reported by the state when the information is material to eligibility (i.e., institutionalization).
Because there is no specific statutory or regulatory basis for defining marital status codes, they are being defined in a way that is as flexible for states and data users as possible. States can report at whatever level of granularity is available to them in their system and a data user can choose to use them as-is or roll the values up in broader categories depending on whichever approach best meets their needs. CMS periodically reviews the values reported to MARITAL-STATUS-OTHER-EXPLANATION to determine if states are appropriately using it only when there is no existing MARITAL-STATUS value that reflects the state's marital status description for an individual AND to determine whether it is necessary to add additional T-MSIS MARITAL-STATUS values to reflect commonly used state martial status descriptions for which there is no existing T-MSIS MARITAL-STATUS value. |
| 11/07/2025 |
3.40.0 |
CRX.002.032 |
UPDATE |
Definition |
The field denotes the claims payment system from which the claim was extracted.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = "22" to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis.
For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = "23" to indicate that the sub-capitated network provider provided the service directly to the enrollee.
For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = “23†to indicate that the sub-capitated network provider provided the service directly to the enrollee. |
The field denotes the claims payment system from which the claim was extracted.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = "22" to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis.
For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = "23" to indicate that the sub-capitated network provider provided the service directly to the enrollee.
For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = "23" to indicate that the sub-capitated network provider provided the service directly to the enrollee. |
| 11/07/2025 |
3.40.0 |
CLT.002.056 |
UPDATE |
Definition |
The field denotes the claims payment system from which the claim was extracted.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = "22" to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis.
For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = "23" to indicate that the sub-capitated network provider provided the service directly to the enrollee.
For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = “23†to indicate that the sub-capitated network provider provided the service directly to the enrollee. |
The field denotes the claims payment system from which the claim was extracted.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = "22" to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis.
For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = "23" to indicate that the sub-capitated network provider provided the service directly to the enrollee.
For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = "23" to indicate that the sub-capitated network provider provided the service directly to the enrollee. |
| 11/07/2025 |
3.40.0 |
CIP.002.104 |
UPDATE |
Definition |
The field denotes the claims payment system from which the claim was extracted.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = "22" to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis.
For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = "23" to indicate that the sub-capitated network provider provided the service directly to the enrollee.
For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = “23†to indicate that the sub-capitated network provider provided the service directly to the enrollee. |
The field denotes the claims payment system from which the claim was extracted.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = "22" to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis.
For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = "23" to indicate that the sub-capitated network provider provided the service directly to the enrollee.
For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = "23" to indicate that the sub-capitated network provider provided the service directly to the enrollee. |
| 11/07/2025 |
3.40.0 |
CRX.002.058 |
UPDATE |
Definition |
The field denotes whether the payment amount was determined at the claim header or line/detail level.
For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines’ associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only.
For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header.
For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed.
For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
The field denotes whether the payment amount was determined at the claim header or line/detail level.
For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines' associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only.
For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header.
For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed.
For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
| 11/07/2025 |
3.40.0 |
CRX.002.029 |
UPDATE |
Definition |
A code to indicate what type of payment is covered in this claim.
For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = "3" for a Medicaid sub-capitated encounter record or “C†for an S-CHIP sub-capitated encounter record. |
A code to indicate what type of payment is covered in this claim.
For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = "3" for a Medicaid sub-capitated encounter record or "C" for an S-CHIP sub-capitated encounter record. |
| 11/07/2025 |
3.40.0 |
COT.002.068 |
UPDATE |
Definition |
The field denotes whether the payment amount was determined at the claim header or line/detail level.
For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines’ associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only.
For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header.
For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed.
For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
The field denotes whether the payment amount was determined at the claim header or line/detail level.
For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines' associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only.
For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header.
For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed.
For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
| 11/07/2025 |
3.40.0 |
COT.002.037 |
UPDATE |
Definition |
A code to indicate what type of payment is covered in this claim.
For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = "3" for a Medicaid sub-capitated encounter record or “C†for an S-CHIP sub-capitated encounter record.
For sub-capitation payments, report TYPE-OF-CLAIM = "6" or “Fâ€. |
A code to indicate what type of payment is covered in this claim.
For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = "3" for a Medicaid sub-capitated encounter record or "C" for an S-CHIP sub-capitated encounter record.
For sub-capitation payments, report TYPE-OF-CLAIM = "6" or "F". |
| 11/07/2025 |
3.40.0 |
CLT.002.082 |
UPDATE |
Definition |
The field denotes whether the payment amount was determined at the claim header or line/detail level.
For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines’ associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only.
For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header.
For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed.
For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
The field denotes whether the payment amount was determined at the claim header or line/detail level.
For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines' associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only.
For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header.
For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed.
For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
| 11/07/2025 |
3.40.0 |
CLT.002.052 |
UPDATE |
Definition |
A code to indicate what type of payment is covered in this claim.
For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = "3" for a Medicaid sub-capitated encounter record or “C†for an S-CHIP sub-capitated encounter record. |
A code to indicate what type of payment is covered in this claim.
For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = "3" for a Medicaid sub-capitated encounter record or "C" for an S-CHIP sub-capitated encounter record. |
| 11/07/2025 |
3.40.0 |
CIP.002.132 |
UPDATE |
Definition |
The field denotes whether the payment amount was determined at the claim header or line/detail level.
For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines’ associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only.
For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header.
For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed.
For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
The field denotes whether the payment amount was determined at the claim header or line/detail level.
For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines' associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only.
For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header.
For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed.
For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
| 11/07/2025 |
3.40.0 |
CIP.002.100 |
UPDATE |
Definition |
A code to indicate what type of payment is covered in this claim. For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = "3" for a Medicaid sub-capitated encounter record or “C†for an S-CHIP sub-capitated encounter record. |
A code to indicate what type of payment is covered in this claim. For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = "3" for a Medicaid sub-capitated encounter record or "C" for an S-CHIP sub-capitated encounter record. |
| 11/07/2025 |
3.40.0 |
ELG.003.269 |
UPDATE |
Definition |
This data element provides the beneficiary's or their household's income as a percentage of the federal poverty level. Used to assign the beneficiary to the eligibility group that covered their Medicaid or CHIP benefits. If the beneficiary's income was assessed using multiple methodologies (MAGI and Non-MAGI), report the income that applies to their primary eligibility group.
A beneficiary’s income is applicable unless it is not required by the eligibility group for which they were determined eligible. For example, the eligibility groups for children with adoption assistance, foster care, or guardianship care under title IV-E and optional eligibility for individuals needing treatment for breast or cervical cancer do not have a Medicaid income test. Additionally, for individuals receiving SSI, states with section 1634 agreements with the Social Security Administration (SSA) and states that use SSI financial methodologies for Medicaid determinations do not conduct separate Medicaid financial eligibility for this group. |
This data element provides the beneficiary's or their household's income as a percentage of the federal poverty level. Used to assign the beneficiary to the eligibility group that covered their Medicaid or CHIP benefits. If the beneficiary's income was assessed using multiple methodologies (MAGI and Non-MAGI), report the income that applies to their primary eligibility group.
A beneficiary's income is applicable unless it is not required by the eligibility group for which they were determined eligible. For example, the eligibility groups for children with adoption assistance, foster care, or guardianship care under title IV-E and optional eligibility for individuals needing treatment for breast or cervical cancer do not have a Medicaid income test. Additionally, for individuals receiving SSI, states with section 1634 agreements with the Social Security Administration (SSA) and states that use SSI financial methodologies for Medicaid determinations do not conduct separate Medicaid financial eligibility for this group. |
| 02/27/2025 |
3.34.0 |
ELG.002.023 |
UPDATE |
Coding requirement |
1. Value must be in Sex List (VVL)2. Value must be 1 character3. (Pregnancy) if value equals "M", then associated Pregnancy Indicator (ELG.003.049) value must not equal "1"4. Mandatory |
1. Value must be in Sex List (VVL)2. Value must be 1 character4. Mandatory |
| 02/26/2025 |
3.34.0 |
RULE-7899 |
UPDATE |
Ta max |
0.05 |
0.02 |
| 02/26/2025 |
3.34.0 |
EL-15-002-2 |
UPDATE |
Specification |
STEP 1: Performance indicator CHIP countRetrieve the PI CHIP enrollment count from the PI data. This is an external source. More information is available at: https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/sdis/index.htmlNote: The PI CHIP enrollment count is not always available for the T-MSIS DQ analysis month at the time of the measure calculation. In such cases, the DQ team will wait until the PI data are ready to do the calculation, so that the PI count and T-MSIS count are for the same month.STEP 2: CHIP enrollee countUse the measure statistic from EL-S-003-3STEP 3: DifferenceSubtract the count of PI CHIP enrollment from STEP 1 from the count of CHIP enrollees from STEP 2STEP 4: PercentageDivide the difference from STEP 3 by the PI CHIP count from STEP 1 |
STEP 1: Performance indicator CHIP countRetrieve the PI CHIP enrollment count from the PI data. This is an external source. More information is available at: https://www.medicaid.gov/medicaid/national-medicaid-chip-program-information/medicaid-chip-enrollment-data/monthly-medicaid-chip-application-eligibility-determination-and-enrollment-reports-data/index.htmlNote: The PI CHIP enrollment count is not always available for the T-MSIS DQ analysis month at the time of the measure calculation. In such cases, the DQ team will wait until the PI data are ready to do the calculation, so that the PI count and T-MSIS count are for the same month.STEP 2: CHIP enrollee countUse the measure statistic from EL-S-003-3STEP 3: DifferenceSubtract the count of PI CHIP enrollment from STEP 1 from the count of CHIP enrollees from STEP 2STEP 4: PercentageDivide the difference from STEP 3 by the PI CHIP count from STEP 1 |
| 02/26/2025 |
3.34.0 |
EL-15-001-1 |
UPDATE |
Specification |
STEP 1: Performance indicator enrollment count Retrieve the total PI enrollment count (Medicaid + CHIP) from the PI data. This is an external source. More information is available at: https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/sdis/index.html Note: The PI enrollment count is not always available for the T-MSIS DQ analysis month at the time of the measure calculation. In such cases, the DQ team will wait until the PI data are ready to do the calculation, so that the PI count and T-MSIS count are for the same month.STEP 2: Full-benefit enrollee countUse the measure statistic from EL-6-023-23STEP 3: Difference Subtract the count of total PI enrollment from STEP 1 from the count of full-benefit enrollees from STEP 2STEP 4: PercentageDivide the difference from STEP 3 by the count in STEP 1 |
STEP 1: Performance indicator enrollment count Retrieve the total PI enrollment count (Medicaid + CHIP) from the PI data. This is an external source. More information is available at: https://www.medicaid.gov/medicaid/national-medicaid-chip-program-information/medicaid-chip-enrollment-data/monthly-medicaid-chip-application-eligibility-determination-and-enrollment-reports-data/index.htmlNote: The PI enrollment count is not always available for the T-MSIS DQ analysis month at the time of the measure calculation. In such cases, the DQ team will wait until the PI data are ready to do the calculation, so that the PI count and T-MSIS count are for the same month.STEP 2: Full-benefit enrollee countUse the measure statistic from EL-6-023-23STEP 3: Difference Subtract the count of total PI enrollment from STEP 1 from the count of full-benefit enrollees from STEP 2STEP 4: PercentageDivide the difference from STEP 3 by the count in STEP 1 |
| 02/26/2025 |
3.34.0 |
Data Quality Measures |
UPDATE |
Version text |
3.13 |
3.13.1 |
| 12/18/2024 |
3.33.0 |
Data Quality Measures |
UPDATE |
Version text |
3.13.0 |
3.13 |
| 02/27/2025 |
3.34.0 |
CRX.002.162 |
UPDATE |
Coding requirement |
1. Value must be one digit2. Value must be 1:43. Conditional |
1. Value must be one digit2. Value must be in Prescription Origin Code List (VVL)3. Conditional |
| 12/10/2024 |
3.33.0 |
CRX.002.162 |
UPDATE |
Medicaid valid value info |
See https://www.ncpdp.org/ |
For background and context, see https://www.ncpdp.org/ |
| 12/18/2024 |
3.33.0 |
RULE-7785 |
UPDATE |
Adjustment type |
Original |
Non-void |
| 10/07/2024 |
3.30.0 |
RULE-7785 |
ADD |
N/A |
|
Created |
| 12/18/2024 |
3.33.0 |
RULE-7784 |
UPDATE |
Adjustment type |
Original |
Non-void |
| 10/07/2024 |
3.30.0 |
RULE-7784 |
ADD |
N/A |
|
Created |
| 12/18/2024 |
3.33.0 |
RULE-7783 |
UPDATE |
Adjustment type |
Original |
Non-void |
| 10/07/2024 |
3.30.0 |
RULE-7783 |
ADD |
N/A |
|
Created |
| 12/18/2024 |
3.33.0 |
RULE-7782 |
UPDATE |
Adjustment type |
Original |
Non-void |
| 10/07/2024 |
3.30.0 |
RULE-7782 |
ADD |
N/A |
|
Created |
| 12/18/2024 |
3.33.0 |
RULE-7936 |
UPDATE |
Adjustment type |
Original |
Original and Replacement |
| 10/07/2024 |
3.30.0 |
RULE-7936 |
ADD |
N/A |
|
Created |
| 12/18/2024 |
3.33.0 |
RULE-7935 |
UPDATE |
Measure name |
% of claim headers with a Servicing Provider Number that does not have a match in PRV00007 with an active provider enrollment status on Ending Date of Service |
% of claim lines with a Servicing Provider Number that does not have a match in PRV00007 with an active provider enrollment status on Ending Date of Service |
| 12/18/2024 |
3.33.0 |
RULE-7935 |
UPDATE |
Adjustment type |
Original |
Original and Replacement |
| 10/07/2024 |
3.30.0 |
RULE-7935 |
ADD |
N/A |
|
Created |
| 12/18/2024 |
3.33.0 |
RULE-7934 |
UPDATE |
Measure name |
% of claim headers with a Servicing Provider Number that does not have a match in PRV00007 with an active provider enrollment status on Ending Date of Service |
% of claim lines with a Servicing Provider Number that does not have a match in PRV00007 with an active provider enrollment status on Ending Date of Service |
| 12/18/2024 |
3.33.0 |
RULE-7934 |
UPDATE |
Adjustment type |
Original |
Original and Replacement |
| 10/07/2024 |
3.30.0 |
RULE-7934 |
ADD |
N/A |
|
Created |
| 12/18/2024 |
3.33.0 |
RULE-7933 |
UPDATE |
Measure name |
% of claim headers with a Servicing Provider Number that does not have a match in PRV00007 with an active provider enrollment status on Ending Date of Service |
% of claim lines with a Servicing Provider Number that does not have a match in PRV00007 with an active provider enrollment status on Ending Date of Service |
| 12/18/2024 |
3.33.0 |
RULE-7933 |
UPDATE |
Adjustment type |
Original |
Original and Replacement |
| 10/07/2024 |
3.30.0 |
RULE-7933 |
ADD |
N/A |
|
Created |
| 12/18/2024 |
3.33.0 |
RULE-7928 |
UPDATE |
Adjustment type |
Original |
Original and Replacement |
| 12/18/2024 |
3.33.0 |
RULE-7928 |
UPDATE |
Focus area |
N/A |
Managed care |
| 10/07/2024 |
3.30.0 |
RULE-7928 |
ADD |
N/A |
|
Created |
| 12/18/2024 |
3.33.0 |
RULE-7927 |
UPDATE |
Measure name |
% of claim headers with a Servicing Provider Number that does not have a match in PRV00007 with an active provider enrollment status on Ending Date of Service |
% of claim lines with a Servicing Provider Number that does not have a match in PRV00007 with an active provider enrollment status on Ending Date of Service |
| 12/18/2024 |
3.33.0 |
RULE-7927 |
UPDATE |
Adjustment type |
Original |
Original and Replacement |
| 12/18/2024 |
3.33.0 |
RULE-7927 |
UPDATE |
Focus area |
N/A |
Managed care |
| 10/07/2024 |
3.30.0 |
RULE-7927 |
ADD |
N/A |
|
Created |
| 12/18/2024 |
3.33.0 |
RULE-7926 |
UPDATE |
Measure name |
% of claim headers with a Servicing Provider Number that does not have a match in PRV00007 with an active provider enrollment status on Ending Date of Service |
% of claim lines with a Servicing Provider Number that does not have a match in PRV00007 with an active provider enrollment status on Ending Date of Service |
| 12/18/2024 |
3.33.0 |
RULE-7926 |
UPDATE |
Adjustment type |
Original |
Original and Replacement |
| 12/18/2024 |
3.33.0 |
RULE-7926 |
UPDATE |
Focus area |
N/A |
Managed care |
| 10/07/2024 |
3.30.0 |
RULE-7926 |
ADD |
N/A |
|
Created |
| 12/18/2024 |
3.33.0 |
RULE-7925 |
UPDATE |
Measure name |
% of claim headers with a Servicing Provider Number that does not have a match in PRV00007 with an active provider enrollment status on Ending Date of Service |
% of claim lines with a Servicing Provider Number that does not have a match in PRV00007 with an active provider enrollment status on Ending Date of Service |
| 12/18/2024 |
3.33.0 |
RULE-7925 |
UPDATE |
Adjustment type |
Original |
Original and Replacement |
| 12/18/2024 |
3.33.0 |
RULE-7925 |
UPDATE |
Focus area |
N/A |
Managed care |
| 10/07/2024 |
3.30.0 |
RULE-7925 |
ADD |
N/A |
|
Created |
| 12/18/2024 |
3.33.0 |
RULE-7932 |
UPDATE |
Adjustment type |
Original |
Original and Replacement |
| 10/07/2024 |
3.30.0 |
RULE-7932 |
ADD |
N/A |
|
Created |
| 12/18/2024 |
3.33.0 |
RULE-7931 |
UPDATE |
Adjustment type |
Original |
Original and Replacement |
| 10/07/2024 |
3.30.0 |
RULE-7931 |
ADD |
N/A |
|
Created |
| 12/18/2024 |
3.33.0 |
RULE-7930 |
UPDATE |
Adjustment type |
Original |
Original and Replacement |
| 10/07/2024 |
3.30.0 |
RULE-7930 |
ADD |
N/A |
|
Created |
| 12/18/2024 |
3.33.0 |
RULE-7929 |
UPDATE |
Adjustment type |
Original |
Original and Replacement |
| 10/07/2024 |
3.30.0 |
RULE-7929 |
ADD |
N/A |
|
Created |
| 12/18/2024 |
3.33.0 |
RULE-7924 |
UPDATE |
Adjustment type |
Original |
Original and Replacement |
| 12/18/2024 |
3.33.0 |
RULE-7924 |
UPDATE |
Focus area |
N/A |
Managed care |
| 10/07/2024 |
3.30.0 |
RULE-7924 |
ADD |
N/A |
|
Created |
| 12/18/2024 |
3.33.0 |
RULE-7923 |
UPDATE |
Adjustment type |
Original |
Original and Replacement |
| 12/18/2024 |
3.33.0 |
RULE-7923 |
UPDATE |
Focus area |
N/A |
Managed care |
| 10/07/2024 |
3.30.0 |
RULE-7923 |
ADD |
N/A |
|
Created |
| 12/18/2024 |
3.33.0 |
RULE-7922 |
UPDATE |
Adjustment type |
Original |
Original and Replacement |
| 12/18/2024 |
3.33.0 |
RULE-7922 |
UPDATE |
Focus area |
N/A |
Managed care |
| 10/07/2024 |
3.30.0 |
RULE-7922 |
ADD |
N/A |
|
Created |
| 12/18/2024 |
3.33.0 |
RULE-7921 |
UPDATE |
Adjustment type |
Original |
Original and Replacement |
| 12/18/2024 |
3.33.0 |
RULE-7921 |
UPDATE |
Focus area |
N/A |
Managed care |
| 10/07/2024 |
3.30.0 |
RULE-7921 |
ADD |
N/A |
|
Created |
| 12/18/2024 |
3.33.0 |
RULE-7975 |
UPDATE |
Claim type |
Medicaid,Enc or CHIP,Enc |
Medicaid,FFS or CHIP,FFS |
| 10/07/2024 |
3.30.0 |
RULE-7975 |
ADD |
N/A |
|
Created |
| 10/07/2024 |
3.30.0 |
RULE-7974 |
ADD |
N/A |
|
Created |
| 10/07/2024 |
3.30.0 |
RULE-7979 |
ADD |
N/A |
|
Created |
| 10/07/2024 |
3.30.0 |
RULE-7978 |
ADD |
N/A |
|
Created |
| 10/07/2024 |
3.30.0 |
RULE-7977 |
ADD |
N/A |
|
Created |
| 10/07/2024 |
3.30.0 |
RULE-7976 |
ADD |
N/A |
|
Created |
| 10/07/2024 |
3.30.0 |
RULE-7636 |
ADD |
N/A |
|
Created |
| 10/07/2024 |
3.30.0 |
RULE-7635 |
ADD |
N/A |
|
Created |
| 10/07/2024 |
3.30.0 |
RULE-7634 |
ADD |
N/A |
|
Created |
| 10/07/2024 |
3.30.0 |
RULE-7633 |
ADD |
N/A |
|
Created |
| 12/18/2024 |
3.33.0 |
RULE-7900 |
UPDATE |
Adjustment type |
All Adjustment Types |
Non-void |
| 10/07/2024 |
3.30.0 |
RULE-7900 |
ADD |
N/A |
|
Created |
| 12/18/2024 |
3.33.0 |
RULE-7899 |
UPDATE |
Adjustment type |
All Adjustment Types |
Non-void |
| 10/07/2024 |
3.30.0 |
RULE-7899 |
ADD |
N/A |
|
Created |
| 12/18/2024 |
3.33.0 |
RULE-7898 |
UPDATE |
Adjustment type |
All Adjustment Types |
Non-void |
| 10/07/2024 |
3.30.0 |
RULE-7898 |
ADD |
N/A |
|
Created |
| 12/18/2024 |
3.33.0 |
RULE-7897 |
UPDATE |
Adjustment type |
All Adjustment Types |
Non-void |
| 10/07/2024 |
3.30.0 |
RULE-7897 |
ADD |
N/A |
|
Created |
| 12/18/2024 |
3.33.0 |
Data Quality Measures |
UPDATE |
Version text |
3.12.1 |
3.13.0 |
| 02/27/2025 |
3.34.0 |
ELG.005.097 |
UPDATE |
Coding requirement |
1. Value must be in Restricted Benefits Code List (VVL)2. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "05", then Eligibility Group (ELG.005.087) must be "24"3. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "06", then Eligibility Group (ELG.005.087) must be "26"4. (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "02", then Eligibility Group (ELG.005.087) must be "23"5. (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "04", then Eligibility Group (ELG.005.087) must be "25"6. (Restricted Benefits) if value is "3", then Dual Eligible Code (ELG.005.085) cannot be "00"7. Mandatory8. If value is populated, then Eligibility Group (ELG.005.087) must be populated9. If value is "6" then Eligibility Group(ELG.DE.087) must be in [35,70]10. If value is "1" or "7" then Eligibility Group (EGL.DE.087) must be in [72,73,74,75] and State Plan Option Type (ELG.DE.163) must equal "06"11. (Restricted Pregnancy-Related) if value is "4", then associated Sex (ELG.002.023) value must be "F"12. (Non-Citizen) if value is "2", then associated Citizenship Indicator (ELG.003.040) value must not be equal to "1"13. If value is "D", there must be a corresponding MFP enrollment segment (ELG00010) with Effective and End dates that are within the timespan of this segment14. Value must be 1 character15. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "01", then Eligibility Group (ELG.005.087) must be "23"16. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "03", then Eligibility Group (ELG.005.087) must be "25"17. (Restricted Benefits) if value is "G", then Dual Eligible Code (ELG.005.085) must be in [01,03,06] |
1. Value must be in Restricted Benefits Code List (VVL)2. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "05", then Eligibility Group (ELG.005.087) must be "24"3. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "06", then Eligibility Group (ELG.005.087) must be "26"4. (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "02", then Eligibility Group (ELG.005.087) must be "23"5. (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "04", then Eligibility Group (ELG.005.087) must be "25"6. (Restricted Benefits) if value is "3", then Dual Eligible Code (ELG.005.085) cannot be "00"7. Mandatory8. If value is populated, then Eligibility Group (ELG.005.087) must be populated9. If value is "6" then Eligibility Group(ELG.DE.087) must be in [35,70]10. If value is "1" or "7" then Eligibility Group (EGL.DE.087) must be in [72,73,74,75] and State Plan Option Type (ELG.DE.163) must equal "06"11. (Restricted Benefits) if value is "G", then Dual Eligible Code (ELG.005.085) must be in [01,03,06]12. (Non-Citizen) if value is "2", then associated Citizenship Indicator (ELG.003.040) value must not be equal to "1"13. If value is "D", there must be a corresponding MFP enrollment segment (ELG00010) with Effective and End dates that are within the timespan of this segment14. Value must be 1 character15. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "01", then Eligibility Group (ELG.005.087) must be "23"16. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "03", then Eligibility Group (ELG.005.087) must be "25" |
| 02/27/2025 |
3.34.0 |
ELG.003.269 |
UPDATE |
Definition |
This data element provides the beneficiary's or their household's income as a percentage of the federal poverty level. Used to assign the beneficiary to the eligibility group that covered their Medicaid or CHIP benefits. If the beneficiary's income was assessed using multiple methodologies (MAGI and Non-MAGI), report the income that applies to their primary eligibility group.
A beneficiary’s income is applicable unless it is not required by the eligibility group for which they were determined eligible. For example, the eligibility groups for children with adoption assistance, foster care, or guardianship care under title IV-E and optional eligibility for individuals needing treatment for breast or cervical cancer do not have a Medicaid income test. Additionally, for individuals receiving SSI, states with section 1634 agreements with the Social Security Administration (SSA) and states that use SSI financial methodologies for Medicaid determinations do not conduct separate Medicaid financial eligibility for this group. |
This data element provides the beneficiary's or their household's income as a percentage of the federal poverty level. Used to assign the beneficiary to the eligibility group that covered their Medicaid or CHIP benefits. If the beneficiary's income was assessed using multiple methodologies (MAGI and Non-MAGI), report the income that applies to their primary eligibility group.
A beneficiary’s income is applicable unless it is not required by the eligibility group for which they were determined eligible. For example, the eligibility groups for children with adoption assistance, foster care, or guardianship care under title IV-E and optional eligibility for individuals needing treatment for breast or cervical cancer do not have a Medicaid income test. Additionally, for individuals receiving SSI, states with section 1634 agreements with the Social Security Administration (SSA) and states that use SSI financial methodologies for Medicaid determinations do not conduct separate Medicaid financial eligibility for this group. |
| 02/27/2025 |
3.34.0 |
ELG.003.044 |
UPDATE |
Definition |
The date the five-year bar for an individual ends. Section 403 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) provides that certain immigrants who enter the United States on or after August 22, 1996 are not eligible to receive federally-funded benefits, including Medicaid and the State Children's Health Insurance Program (Separate CHIP), for five years from the date they enter the country with a status as a "qualified alien." |
The date the five-year bar for an individual ends. Section 403 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) provides that certain immigrants who enter the United States on or after August 22, 1996 are not eligible to receive federally-funded benefits, including Medicaid and the State Children's Health Insurance Program (Separate CHIP), for five years from the date they enter the country with a status as a "qualified noncitizen." |
| 02/27/2025 |
3.34.0 |
ELG.003.038 |
UPDATE |
Definition |
A code indicating the federal poverty level range in which the family income falls.
If the beneficiary's income was assessed using multiple methodologies (MAGI and Non-MAGI), report the income that applies to their primary eligibility group.
A beneficiary’s income is applicable unless it is not required by the eligibility group for which they were determined eligible. For example, the eligibility groups for children with adoption assistance, foster care, or guardianship care under title IV-E and optional eligibility for individuals needing treatment for breast or cervical cancer do not have a Medicaid income test. Additionally, for individuals receiving SSI, states with section 1634 agreements with the Social Security Administration (SSA) and states that use SSI financial methodologies for Medicaid determinations do not conduct separate Medicaid financial eligibility for this group. |
A code indicating the federal poverty level range in which the family income falls.
If the beneficiary's income was assessed using multiple methodologies (MAGI and Non-MAGI), report the income that applies to their primary eligibility group.
A beneficiary’s income is applicable unless it is not required by the eligibility group for which they were determined eligible. For example, the eligibility groups for children with adoption assistance, foster care, or guardianship care under title IV-E and optional eligibility for individuals needing treatment for breast or cervical cancer do not have a Medicaid income test. Additionally, for individuals receiving SSI, states with section 1634 agreements with the Social Security Administration (SSA) and states that use SSI financial methodologies for Medicaid determinations do not conduct separate Medicaid financial eligibility for this group. |
| 02/27/2025 |
3.34.0 |
ELG.003.034 |
UPDATE |
Definition |
A code to classify eligible individual's marital/domestic-relationship status. This element should be reported by the state when the information is material to eligibility (i.e., institutionalization).
Because there is no specific statutory or regulatory basis for defining marital status codes, they are being defined in a way that is as flexible for states and data users as possible. States can report at whatever level of granularity is available to them in their system and a data user can choose to use them as-is or roll the values up in broader categories depending on whichever approach best meets their needs. CMS periodically reviews the values reported to MARITAL-STATUS-OTHER-EXPLANATION to determine if states are appropriately using it only when there is no existing MARITAL-STATUS value that reflects the state’s marital status description for an individual AND to determine whether it is necessary to add additional T-MSIS MARITAL-STATUS values to reflect commonly used state martial status descriptions for which there is no existing T-MSIS MARITAL-STATUS value. |
A code to classify eligible individual's marital/domestic-relationship status. This element should be reported by the state when the information is material to eligibility (i.e., institutionalization).
Because there is no specific statutory or regulatory basis for defining marital status codes, they are being defined in a way that is as flexible for states and data users as possible. States can report at whatever level of granularity is available to them in their system and a data user can choose to use them as-is or roll the values up in broader categories depending on whichever approach best meets their needs. CMS periodically reviews the values reported to MARITAL-STATUS-OTHER-EXPLANATION to determine if states are appropriately using it only when there is no existing MARITAL-STATUS value that reflects the state’s marital status description for an individual AND to determine whether it is necessary to add additional T-MSIS MARITAL-STATUS values to reflect commonly used state martial status descriptions for which there is no existing T-MSIS MARITAL-STATUS value. |
| 02/20/2025 |
3.34.0 |
ELG.002.023 |
UPDATE |
Definition |
Either individual's biological sex or their self-identified sex. |
The individual's biological sex assigned at birth. |
| 02/27/2025 |
3.34.0 |
CRX.003.150 |
UPDATE |
Coding requirement |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is "01", then a valid value is mandatory and must be reported5. If value is in [14,35,42,44], then Sex (ELG.002.023) must not equals "M"6. If XXI MBESCBES Category of Service is populated then must not be populated |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is "01", then a valid value is mandatory and must be reported5. If XXI MBESCBES Category of Service is populated then must not be populated |
| 09/30/2024 |
3.30.0 |
CRX.002.069 |
UPDATE |
Coding requirement |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be "01" or in [21-30](1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20,32,33]6. Conditional |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be "01" or in [21-30]4. (1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20,32,33]6. Conditional |
| 02/27/2025 |
3.34.0 |
CRX.002.058 |
UPDATE |
Definition |
The field denotes whether the payment amount was determined at the claim header or line/detail level.
For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines’ associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only.
For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header.
For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed.
For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
The field denotes whether the payment amount was determined at the claim header or line/detail level.
For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines’ associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only.
For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header.
For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed.
For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
| 02/27/2025 |
3.34.0 |
CRX.002.032 |
UPDATE |
Definition |
The field denotes the claims payment system from which the claim was extracted.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = "22" to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis.
For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = "23" to indicate that the sub-capitated network provider provided the service directly to the enrollee.
For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = “23” to indicate that the sub-capitated network provider provided the service directly to the enrollee. |
The field denotes the claims payment system from which the claim was extracted.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = "22" to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis.
For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = "23" to indicate that the sub-capitated network provider provided the service directly to the enrollee.
For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = “23†to indicate that the sub-capitated network provider provided the service directly to the enrollee. |
| 02/27/2025 |
3.34.0 |
CRX.002.029 |
UPDATE |
Definition |
A code to indicate what type of payment is covered in this claim.
For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = "3" for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record. |
A code to indicate what type of payment is covered in this claim.
For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = "3" for a Medicaid sub-capitated encounter record or “C†for an S-CHIP sub-capitated encounter record. |
| 02/27/2025 |
3.34.0 |
COT.003.211 |
UPDATE |
Coding requirement |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is "01",then a valid value is mandatory and must be reported5. If value is in [14,35,42,44],then Sex (ELG.002.023) must not equals "M"6. If XXI MBESCBES Category of Service is populated then must not be populated |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is "01",then a valid value is mandatory and must be reported5. If XXI MBESCBES Category of Service is populated then must not be populated |
| 02/27/2025 |
3.34.0 |
COT.003.186 |
UPDATE |
Coding requirement |
1. Value must be 3 characters2. Mandatory3. When value is in [119-122],Servicing Provider NPI Num (COT.002.190) should not be populated4. Value must be in [002,003,004,005,006,007,008,010,011,012,013,014,015,016,017,018,019,020,021,022,023,024,025,026,027,028,029,030,031,032,035,036,037,038,039,040,041,042,043,049,050,051,052,053,054,055,056,057,058,060,061,062,063,064,065,066,067,068,069,070,071,072,073,074,075,076,077,078,079,080,081,082,083,084,085,086,087,088,089,115,119,120,121,122,127,131,134,135,136,137,138,139,140,141,142,143,144,145,147]5. When value is in [119-122], Servicing Provider Taxonomy (COT.003.191) should not be populated6. When value is in [119-122], Referring Provider NPI Num (COT.002.118) should not be populated7. Value must be 3 characters8. When value is in [119-122], Billing Provider NPI Num (COT.002.113) should not be populated9. When value is in [119-122], Billing Provider Taxonomy (COT.002.114) should not be populated10. When value is in [119-122], Referring Provider Taxonomy (COT.002.119) should not be populated11. When value is not in [025,085], Sex (ELG.002.023) equals "M"12. When value is in [119-122], Servicing Provider Num (COT.002.189) should not be populated |
1. Value must be 3 characters2. Mandatory3. When value is in [119-122],Servicing Provider NPI Num (COT.002.190) should not be populated4. Value must be in [002,003,004,005,006,007,008,010,011,012,013,014,015,016,017,018,019,020,021,022,023,024,025,026,027,028,029,030,031,032,035,036,037,038,039,040,041,042,043,049,050,051,052,053,054,055,056,057,058,060,061,062,063,064,065,066,067,068,069,070,071,072,073,074,075,076,077,078,079,080,081,082,083,084,085,086,087,088,089,115,119,120,121,122,127,131,134,135,136,137,138,139,140,141,142,143,144,145,147]5. When value is in [119-122], Servicing Provider Taxonomy (COT.003.191) should not be populated6. When value is in [119-122], Referring Provider NPI Num (COT.002.118) should not be populated7. Value must be 3 characters8. When value is in [119-122], Billing Provider NPI Num (COT.002.113) should not be populated9. When value is in [119-122], Billing Provider Taxonomy (COT.002.114) should not be populated10. When value is in [119-122], Referring Provider Taxonomy (COT.002.119) should not be populated11. When value is in [119-122], Servicing Provider Num (COT.002.189) should not be populated |
| 09/30/2024 |
3.30.0 |
COT.002.111 |
UPDATE |
Coding requirement |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be "01" or in [21-30](1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Conditional |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be "01" or in [21-30]4. (1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Conditional |
| 02/27/2025 |
3.34.0 |
COT.002.068 |
UPDATE |
Definition |
The field denotes whether the payment amount was determined at the claim header or line/detail level.
For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines’ associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only.
For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header.
For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed.
For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
The field denotes whether the payment amount was determined at the claim header or line/detail level.
For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines’ associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only.
For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header.
For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed.
For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
| 02/27/2025 |
3.34.0 |
COT.002.037 |
UPDATE |
Definition |
A code to indicate what type of payment is covered in this claim.
For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = "3" for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record.
For sub-capitation payments, report TYPE-OF-CLAIM = "6" or “F”. |
A code to indicate what type of payment is covered in this claim.
For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = "3" for a Medicaid sub-capitated encounter record or “C†for an S-CHIP sub-capitated encounter record.
For sub-capitation payments, report TYPE-OF-CLAIM = "6" or “Fâ€. |
| 02/27/2025 |
3.34.0 |
CLT.003.224 |
UPDATE |
Coding requirement |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is "01", then a valid value is mandatory and must be reported5. If value is in [14,35,42,44], then Sex (ELG.002.023) must not equal "M"6. If XXI MBESCBES Category of Service is populated, then must not be populated |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is "01", then a valid value is mandatory and must be reported5. If XXI MBESCBES Category of Service is populated, then must not be populated |
| 09/30/2024 |
3.30.0 |
CLT.002.129 |
UPDATE |
Coding requirement |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be "01" or in [21-30](1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20,32,33]6. Conditional |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be "01" or in [21-30]4. (1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20,32,33]6. Conditional |
| 02/27/2025 |
3.34.0 |
CLT.002.082 |
UPDATE |
Definition |
The field denotes whether the payment amount was determined at the claim header or line/detail level.
For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines’ associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only.
For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header.
For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed.
For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
The field denotes whether the payment amount was determined at the claim header or line/detail level.
For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines’ associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only.
For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header.
For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed.
For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
| 02/27/2025 |
3.34.0 |
CLT.002.056 |
UPDATE |
Definition |
The field denotes the claims payment system from which the claim was extracted.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = "22" to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis.
For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = "23" to indicate that the sub-capitated network provider provided the service directly to the enrollee.
For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = “23” to indicate that the sub-capitated network provider provided the service directly to the enrollee. |
The field denotes the claims payment system from which the claim was extracted.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = "22" to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis.
For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = "23" to indicate that the sub-capitated network provider provided the service directly to the enrollee.
For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = “23†to indicate that the sub-capitated network provider provided the service directly to the enrollee. |
| 02/27/2025 |
3.34.0 |
CLT.002.052 |
UPDATE |
Definition |
A code to indicate what type of payment is covered in this claim.
For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = "3" for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record. |
A code to indicate what type of payment is covered in this claim.
For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = "3" for a Medicaid sub-capitated encounter record or “C†for an S-CHIP sub-capitated encounter record. |
| 02/27/2025 |
3.34.0 |
CIP.003.270 |
UPDATE |
Coding requirement |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is "01", then a valid value is mandatory and must be reported5. If value is in [14,35,42,44], then Sex (ELG.002.023) must not equal "M"6. If XXI MBESCBES Category of Service is populated then must not be populated |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is "01", then a valid value is mandatory and must be reported5. If XXI MBESCBES Category of Service is populated then must not be populated |
| 02/27/2025 |
3.34.0 |
CIP.003.257 |
UPDATE |
Coding requirement |
1. Value must be 3 characters2. Mandatory3. Value must not equal "086" if Sex (ELG.002.023) equals "M"4. Value must be in [001,058,060,084,086,090,091,092,093,123,132,135,136,137] |
1. Value must be 3 characters2. Mandatory3. Value must be in [001,058,060,084,086,090,091,092,093,123,132,135,136,137] |
| 09/30/2024 |
3.30.0 |
CIP.002.178 |
UPDATE |
Coding requirement |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30](1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20,32,33]6. Conditional |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20,32,33]6. Conditional |
| 02/27/2025 |
3.34.0 |
CIP.002.132 |
UPDATE |
Definition |
The field denotes whether the payment amount was determined at the claim header or line/detail level.
For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines’ associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only.
For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header.
For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed.
For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
The field denotes whether the payment amount was determined at the claim header or line/detail level.
For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines’ associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only.
For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header.
For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed.
For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
| 02/27/2025 |
3.34.0 |
CIP.002.104 |
UPDATE |
Definition |
The field denotes the claims payment system from which the claim was extracted.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = "22" to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis.
For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = "23" to indicate that the sub-capitated network provider provided the service directly to the enrollee.
For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = “23” to indicate that the sub-capitated network provider provided the service directly to the enrollee. |
The field denotes the claims payment system from which the claim was extracted.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = "22" to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis.
For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = "23" to indicate that the sub-capitated network provider provided the service directly to the enrollee.
For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = “23†to indicate that the sub-capitated network provider provided the service directly to the enrollee. |
| 02/27/2025 |
3.34.0 |
CIP.002.100 |
UPDATE |
Definition |
A code to indicate what type of payment is covered in this claim. For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = "3" for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record. |
A code to indicate what type of payment is covered in this claim. For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = "3" for a Medicaid sub-capitated encounter record or “C†for an S-CHIP sub-capitated encounter record. |
| 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 |
| 02/26/2025 |
3.34.0 |
EL-6-041-41 |
UPDATE |
Priority |
N/A |
High |
| 02/26/2025 |
3.34.0 |
EL-6-041-41 |
UPDATE |
Category |
N/A |
Beneficiary eligibility |
| 02/26/2025 |
3.34.0 |
EL-6-041-41 |
UPDATE |
For ta comprehensive |
No |
TA- Inferential |
| 02/26/2025 |
3.34.0 |
EL-6-041-41 |
UPDATE |
For ta inferential |
No |
Yes |
| 02/26/2025 |
3.34.0 |
EL-6-041-41 |
UPDATE |
Ta min |
|
0 |
| 02/26/2025 |
3.34.0 |
EL-6-041-41 |
UPDATE |
Ta max |
|
0.05 |
| 02/26/2025 |
3.34.0 |
EL-6-041-41 |
UPDATE |
Threshold minimum |
TBD |
0 |
| 02/26/2025 |
3.34.0 |
EL-6-041-41 |
UPDATE |
Threshold maximum |
TBD |
0.05 |
| 02/26/2025 |
3.34.0 |
EL-6-041-41 |
UPDATE |
Annotation |
N/A |
Calculate the percentage of MSIS IDs enrolled in the past 12 months with at least three gaps in enrollment during that time period |
| 02/26/2025 |
3.34.0 |
EL-6-041-41 |
UPDATE |
Specification |
N/A |
STEP 1: Enrolled at any time within the past 12 monthsDefine 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 >= 12 months prior to last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Enrollment Type is Medicaid or CHIPUsing the MSIS IDs that meet the criteria from STEP 1, further refine the population by keeping records with: 1. ENROLLMENT-TYPE = "1" or "2"STEP 3: Non-duplicate enrollment spansDuplicate records are dropped if the following three data elements are the same: MSIS-IDENTIFICATION-NUM, ENROLLMENT-EFF-DATE, and ENROLLMENT-END-DATESTEP 4: Sort records chronologically for each MSIS IDFor each MSIS ID identified in STEP 2, sort records chronologically by ENROLLMENT-EFF-DATE and ENROLLMENT-END-DATESTEP 5: Maximum enrollment end date thus farFor each combination of ENROLLMENT-EFF-DATE, and ENROLLMENT-END-DATE for a given MSIS ID, set Max_End_Date_Thus_Far = the maximum value for ENROLLMENT-END-DATE for that combinationSTEP 6: Total record count by MSIS IDFor each MSIS ID identified in STEP 2, set Tot_Rec = Count of unique combinations of ENROLLMENT-EFF-DATE and ENROLLMENT-END-DATESTEP 7: Previous enrollment end dateFor each combination of ENROLLMENT-EFF-DATE, and ENROLLMENT-END-DATE for a given MSIS ID, set Prev_Enrollment_End_Date = the ENROLLMENT-END-DATE value immediately prior to the ENROLLMENT-END-DATE value for that combinationSTEP 8: Enrollment span startFor each combination of ENROLLMENT-EFF-DATE, and ENROLLMENT-END-DATE for a given MSIS ID, set Enrollment_Span_Start = "1" as follows:1a. Tot_Rec = 1 for the MSIS IDOR1b. ENROLLMENT-EFF-DATE is greater than Prev_Enrollment_End_Date ELSESet Enrollment_Span_Start = "0"STEP 9: Total count of noncontiguous enrollment spansFor each MSIS ID that meets the criteria from STEP 2, set Tot_Enrollment_Span = Count of rows where Enrollment_Span_Start = "1"STEP 10: Count of MSIS IDs with three or more enrollment gapsFor each MSIS ID that meets the criteria from STEP 2, further refine the population by keeping records where Tot_Enrollment_Span is greater than 3. Note that since gaps exist between enrollment spans, there must be at least 4 noncontiguous enrollment spans to equal 3 enrollment gaps for a given MSIS ID. STEP 11: Calculate percentage for measureDivide the count of MSIS IDs from STEP 10 by the count of MSIS IDs from STEP 2 |
| 02/26/2025 |
3.34.0 |
EL-6-041-41 |
UPDATE |
Focus area |
N/A |
Enrollment monitoring |
| 06/19/2024 |
3.27.0 |
EL-6-041-41 |
ADD |
N/A |
|
Created |
| 02/26/2025 |
3.34.0 |
EL-3-034-43 |
UPDATE |
Priority |
N/A |
High |
| 02/26/2025 |
3.34.0 |
EL-3-034-43 |
UPDATE |
Category |
N/A |
Beneficiary eligibility |
| 02/26/2025 |
3.34.0 |
EL-3-034-43 |
UPDATE |
For ta comprehensive |
No |
TA- Inferential |
| 02/26/2025 |
3.34.0 |
EL-3-034-43 |
UPDATE |
For ta inferential |
No |
Yes |
| 02/26/2025 |
3.34.0 |
EL-3-034-43 |
UPDATE |
Ta min |
|
0 |
| 02/26/2025 |
3.34.0 |
EL-3-034-43 |
UPDATE |
Ta max |
|
0.3 |
| 02/26/2025 |
3.34.0 |
EL-3-034-43 |
UPDATE |
Threshold minimum |
TBD |
0 |
| 02/26/2025 |
3.34.0 |
EL-3-034-43 |
UPDATE |
Threshold maximum |
TBD |
0.3 |
| 02/26/2025 |
3.34.0 |
EL-3-034-43 |
UPDATE |
Annotation |
N/A |
Calculate the percentage of MSIS IDs with a ELIGIBILITY-GROUP value of "05", where SEX is not "M", that are between the ages of 40 and 44 |
| 02/26/2025 |
3.34.0 |
EL-3-034-43 |
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 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: ELIGIBILITY-GROUP = "05"Of the MSIS IDs that meet the criteria from STEP 2, further refine the population by keeping records with ELIGIBILITY-GROUP = "05"STEP 4: Primary demographics on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 3, join to segment PRIMARY-DEMOGRAPHICS-ELG00002 by keeping records that satisfy the following criteria:1a. PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE <= last day of the DQ report month2a. PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE >= last day of the DQ report month OR missingOR1b. PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE is missing2b. PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE is missingSTEP 5: SEX is not equal to "M"Of the MSIS IDs that meet the criteria from STEP 4, further refine the population by keeping records where SEX is not "M" STEP 6: Calculate AgeOf the MSIS IDs that meet the criteria from STEP 5, calculate age:1a. If DATE-OF-DEATH is non-missing and occurs before the last day of the DQ report month, Age is equal to the years between DATE-OF-DEATH and DATE-OF-BIRTH.1b. Otherwise, Age is equal to the years between the last day of the DQ report month and DATE-OF-BIRTH.STEP 7: Individuals between the ages of 40 and 44Refine the MSIS IDs from STEP 6 by keeping records with:1. Age >= 40 and Age <= 44STEP 8: Calculate percentage for measureDIVIDE the count of MSIS IDs from STEP 7 by the count of MSIS IDs from STEP 3 |
| 06/19/2024 |
3.27.0 |
EL-3-034-43 |
ADD |
N/A |
|
Created |
| 02/26/2025 |
3.34.0 |
EL-3-033-42 |
UPDATE |
Priority |
N/A |
High |
| 02/26/2025 |
3.34.0 |
EL-3-033-42 |
UPDATE |
Category |
N/A |
Beneficiary eligibility |
| 02/26/2025 |
3.34.0 |
EL-3-033-42 |
UPDATE |
For ta comprehensive |
No |
TA- Inferential |
| 02/26/2025 |
3.34.0 |
EL-3-033-42 |
UPDATE |
For ta inferential |
No |
Yes |
| 02/26/2025 |
3.34.0 |
EL-3-033-42 |
UPDATE |
Ta min |
|
0 |
| 02/26/2025 |
3.34.0 |
EL-3-033-42 |
UPDATE |
Ta max |
|
0.05 |
| 02/26/2025 |
3.34.0 |
EL-3-033-42 |
UPDATE |
Threshold minimum |
TBD |
0 |
| 02/26/2025 |
3.34.0 |
EL-3-033-42 |
UPDATE |
Threshold maximum |
TBD |
0.05 |
| 02/26/2025 |
3.34.0 |
EL-3-033-42 |
UPDATE |
Annotation |
N/A |
Calculate the percentage of MSIS IDs with an ELIGIBILITY-GROUP value of "11" that are not receiving full benefits |
| 02/26/2025 |
3.34.0 |
EL-3-033-42 |
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 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: ELIGIBILITY-GROUP = "11"Of the MSIS IDs that meet criteria from STEP 2, futher refine the population by keeping records with ELIGIBILITY-GROUP = "11"STEP 4: Enrollees without full benefitsOf the MSIS ID's that meet the criteria from STEP 3, further refine the population by keeping records that satisfy the following criteria:1. RESTRICTED-BENEFITS-CODE is not ("1", "4", "5" "7", "A", "B", "D") OR2. RESTRICTED-BENEFITS-CODE is missingSTEP: 5: Calculate percentage for measureDIVIDE the count of MSIS IDs from STEP 4 by the count of MSIS IDs from STEP 3 |
| 06/19/2024 |
3.27.0 |
EL-3-033-42 |
ADD |
N/A |
|
Created |
| 12/18/2024 |
3.33.0 |
MCR-59P-004-16 |
UPDATE |
Threshold maximum |
0.3 |
0.01 |
| 12/18/2024 |
3.33.0 |
MCR-56P-001-1 |
UPDATE |
Threshold maximum |
0.01 |
0.05 |
| 12/18/2024 |
3.33.0 |
EXP-41P-001-1 |
UPDATE |
Threshold maximum |
0.05 |
0.1 |
| 12/18/2024 |
3.33.0 |
EXP-22P-009-9 |
UPDATE |
Threshold maximum |
0.05 |
0.1 |
| 12/18/2024 |
3.33.0 |
EXP-37P-001-1-2 |
UPDATE |
Threshold maximum |
0.05 |
0.3 |
| 12/18/2024 |
3.33.0 |
EXP-33P-001-1 |
UPDATE |
Threshold maximum |
0.05 |
0.1 |
| 12/18/2024 |
3.33.0 |
EXP-29P-001-1 |
UPDATE |
Threshold maximum |
0.05 |
0.1 |
| 10/07/2024 |
3.30.0 |
EL-3-029-38 |
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: RESTRICTED-BENEFITS-CODE = "4"Of the MSIS IDs that meet the criteria from STEP 2, further refine the population by keeping records with RESTRICTED-BENEFITS-CODE = "4"STEP 4: Primary demographics on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 3, join to segment PRIMARY-DEMOGRAPHICS-ELG00002 by keeping records that satisfy the following criteria:1a. PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE <= last day of the DQ report month2a. PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE >= last day of the DQ report month OR missingOR1b. PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE is missing2b. PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE is missingSTEP 5: SEX = "M"Of the MSIS IDs that meet the criteria from STEP 4, further refine the population by keeping records with with SEX = "M"STEP 6: Calculate percentage for measureDIVIDE the count of MSIS IDs from STEP 5 by the count of MSIS IDs from STEP 1 |
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: RESTRICTED-BENEFITS-CODE = "4"Of the MSIS IDs that meet the criteria from STEP 2, further refine the population by keeping records with RESTRICTED-BENEFITS-CODE = "4"STEP 4: Primary demographics on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 3, join to segment PRIMARY-DEMOGRAPHICS-ELG00002 by keeping records that satisfy the following criteria:1a. PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE <= last day of the DQ report month2a. PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE >= last day of the DQ report month OR missingOR1b. PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE is missing2b. PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE is missingSTEP 5: SEX = "M"Of the MSIS IDs that meet the criteria from STEP 4, further refine the population by keeping records with with SEX = "M"STEP 6: Calculate percentage for measureDIVIDE the count of MSIS IDs from STEP 5 by the count of MSIS IDs from STEP 3 |
| 10/07/2024 |
3.30.0 |
EL-3-028-37 |
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-DEMOGRAPHICS-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: Pregnancy Indicator = "1"Of the MSIS IDs that meet the criteria from STEP 2, further refine the population by keeping records with PREGNANCY-INDICATOR= "1"STEP 4: Primary demographics on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 3, join to segment PRIMARY-DEMOGRAPHICS-ELG00002 by keeping records that satisfy the following criteria:1a. PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE <= last day of the DQ report month2a. PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE >= last day of the DQ report month OR missingOR1b. PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE is missing2b. PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE is missingSTEP 5: SEX = "M"Of the MSIS IDs that meet the criteria from STEP 4, further refine the population by keeping records with with SEX = "M"STEP 6: Calculate percentage for measureDIVIDE the count of MSIS IDs from STEP 5 by the count of MSIS IDs from STEP 1 |
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-DEMOGRAPHICS-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: Pregnancy Indicator = "1"Of the MSIS IDs that meet the criteria from STEP 2, further refine the population by keeping records with PREGNANCY-INDICATOR= "1"STEP 4: Primary demographics on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 3, join to segment PRIMARY-DEMOGRAPHICS-ELG00002 by keeping records that satisfy the following criteria:1a. PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE <= last day of the DQ report month2a. PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE >= last day of the DQ report month OR missingOR1b. PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE is missing2b. PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE is missingSTEP 5: SEX = "M"Of the MSIS IDs that meet the criteria from STEP 4, further refine the population by keeping records with with SEX = "M"STEP 6: Calculate percentage for measureDIVIDE the count of MSIS IDs from STEP 5 by the count of MSIS IDs from STEP 3 |
| 10/07/2024 |
3.30.0 |
EXP-13-003_1-6 |
UPDATE |
Annotation |
Calculate the percentage of S-CHIP FFS: original, non-crossover, paid OT claims billed at the line level where the total amount billed is $0 |
Calculate the percentage of S-CHIP FFS: original, non-crossover, paid OT claims billed at the line level where the billed amount is $0 |
| 10/07/2024 |
3.30.0 |
EXP-13-003_1-6 |
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: 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 = "A"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: S-CHIP 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 = "A"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 |
| 10/07/2024 |
3.30.0 |
EL-1-009-8 |
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: Ethnicity information on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 1, join to segment ETHNICITY-INFORMATION-ELG00015 by keeping active records that satisfy the following criteria:1a. ETHNICITY-DECLARATION-EFF-DATE <= last day of the DQ report month2a. ETHNICITY-DECLARATION-END-DATE >= last day of the DQ report month OR missingOR1b. ETHNICITY-DECLARATION-EFF-DATE is missing2b. ETHNICITY-DECLARATION-END-DATE is missingSTEP 3: Non-missing ethnicityOf the MSIS IDs that meet the criteria from STEP 2, further refine the population by keeping records with: 1. ETHNICITY-CODE non-missingSTEP 4: Percent ethnicity for the current month1. For each distinct value of ethnicity code, set the number of unique MSIS IDs as Numerator_Count_By_Value. 2. Set the total number of unique MSIS IDs across all valid values of ethnicity code as Denominator_Count. Note that Denominator_Count should also equal to the count of MSIS IDs from STEP 3. 3. For each distinct value of ethnicity code, calculate Percent_Current_Month as the ratio of Numerator_Count_By_Value over Denominator_Count. STEP 5: Percent ethnicity for the previous monthRepeat STEP 1 through STEP 4 for the previous month. For each distinct value of ethnicity code, set the percent of ethnicity code for the previous month as Percent_Prior_Month_1.STEP 6: Calculate change between monthsFor each frequency percent, calculate Frequency_Change as the absolute value of (Percent_Current_Month – Percent_Prior_Month_1) / 2. Note that Frequency_Change is a vector of frequencies.STEP 7: Calculate index of dissimilarityCalculate the index of dissimilarity by summing Frequency_Change across all frequencies and dividing by 100 |
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: Ethnicity information on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 1, join to segment ETHNICITY-INFORMATION-ELG00015 by keeping active records that satisfy the following criteria:1a. ETHNICITY-DECLARATION-EFF-DATE <= last day of the DQ report month2a. ETHNICITY-DECLARATION-END-DATE >= last day of the DQ report month OR missingOR1b. ETHNICITY-DECLARATION-EFF-DATE is missing2b. ETHNICITY-DECLARATION-END-DATE is missingSTEP 3: Non-missing ethnicityOf the MSIS IDs that meet the criteria from STEP 2, further refine the population by keeping records with: 1. ETHNICITY-CODE non-missingSTEP 4: Percent ethnicity for the current month1. For each distinct value of ethnicity code, set the number of unique MSIS IDs as Numerator_Count_By_Value. 2. Sum the total number of unique MSIS IDs within each valid value of ethnicity and set as Denominator_Count. Note that Denominator_Count should also equal to the count of MSIS IDs from STEP 3.3. For each distinct value of ethnicity code, calculate Percent_Current_Month as the ratio of Numerator_Count_By_Value over Denominator_Count. STEP 5: Percent ethnicity for the previous monthRepeat STEP 1 through STEP 4 for the previous month. For each distinct value of ethnicity code, set the percent of ethnicity code for the previous month as Percent_Prior_Month_1.STEP 6: Calculate change between monthsFor each frequency percent, calculate Frequency_Change as the absolute value of (Percent_Current_Month – Percent_Prior_Month_1) / 2. Note that Frequency_Change is a vector of frequencies.STEP 7: Calculate index of dissimilarityCalculate the index of dissimilarity by summing Frequency_Change across all frequencies |
| 10/07/2024 |
3.30.0 |
EL-1-008-7 |
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: 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: Non-missing raceOf the MSIS IDs that meet the criteria from STEP 2, further refine the population by keeping records with: 1. RACE is non-missingSTEP 4: Percent race for the current month1. For each distinct value of race, set the number of unique MSIS IDs as Numerator_Count_By_Value. 2. Set the total number of unique MSIS IDs across all valid values of race as Denominator_Count. Note that Denominator_Count should also equal to the count of MSIS IDs from STEP 3. 3. For each distinct value of race, calculate Percent_Current_Month as the ratio of Numerator_Count_By_Value over Denominator_Count. STEP 5: Percent race for the previous monthRepeat STEP 1 through STEP 4 for the previous month. For each distinct value of race, set the percent of race for the previous month as Percent_Prior_Month_1.STEP 6: Calculate change between monthsFor each frequency percent, calculate Frequency_Change as the absolute value of (Percent_Current_Month – Percent_Prior_Month_1) / 2. Note that Frequency_Change is a vector of frequencies.STEP 7: Calculate index of dissimilarityCalculate the index of dissimilarity by summing Frequency_Change across all frequencies and dividing by 100 |
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: Non-missing raceOf the MSIS IDs that meet the criteria from STEP 2, further refine the population by keeping records with: 1. RACE is non-missingSTEP 4: Percent race for the current month1. For each distinct value of race, set the number of unique MSIS IDs as Numerator_Count_By_Value. 2. Sum the total number of unique MSIS IDs within each valid value of ethnicity and set as Denominator_Count. Note that Denominator_Count should also equal to the count of MSIS IDs from STEP 3.3. For each distinct value of race, calculate Percent_Current_Month as the ratio of Numerator_Count_By_Value over Denominator_Count. STEP 5: Percent race for the previous monthRepeat STEP 1 through STEP 4 for the previous month. For each distinct value of race, set the percent of race for the previous month as Percent_Prior_Month_1.STEP 6: Calculate change between monthsFor each frequency percent, calculate Frequency_Change as the absolute value of (Percent_Current_Month – Percent_Prior_Month_1) / 2. Note that Frequency_Change is a vector of frequencies.STEP 7: Calculate index of dissimilarityCalculate the index of dissimilarity by summing Frequency_Change across all frequencies |
| 10/07/2024 |
3.30.0 |
EL-1-007-5 |
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: Eligible contact information on the last day of 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: Non-missing zip code for primary addressOf the MSIS IDs that meet the criteria from STEP 2, further refine the population by keeping records with: 1. ELIGIBLE-ZIP-CODE non-missing2. ELIGIBLE_ADDRESS_TYPE = "01"STEP 4: Percent eligible zip code for the current month1. For each distinct value of zip code, set the number of unique MSIS IDs as Numerator_Count_By_Value. 2. Set the total number of unique MSIS IDs across all valid values of zip code as Denominator_Count. Note that Denominator_Count should also equal to the count of MSIS IDs from STEP 3. 3. For each distinct value of zip code, calculate Percent_Current_Month as the ratio of Numerator_Count_By_Value over Denominator_Count.STEP 5: Percent zip code for the previous monthRepeat STEP 1 through STEP 4 for the previous month. For each distinct value of zip code, set the percent of zip code for the previous month as Percent_Prior_Month_1. STEP 6: Calculate change between monthsFor each frequency percent, calculate Frequency_Change as the absolute value of (Percent_Current_Month – Percent_Prior_Month_1) / 2. Note that Frequency_Change is a vector of frequencies.STEP 7: Calculate index of dissimilarityCalculate the index of dissimilarity by summing Frequency_Change across all frequencies and dividing by 100 |
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 information on the last day of 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: Non-missing zip code for primary addressOf the MSIS IDs that meet the criteria from STEP 2, further refine the population by keeping records with: 1. ELIGIBLE-ZIP-CODE non-missing2. ELIGIBLE_ADDRESS_TYPE = "01"STEP 4: Percent eligible zip code for the current month1. For each distinct value of zip code, set the number of unique MSIS IDs as Numerator_Count_By_Value. 2. Sum the total number of unique MSIS IDs within each valid value of ethnicity and set as Denominator_Count. Note that Denominator_Count should also equal to the count of MSIS IDs from STEP 3.3. For each distinct value of zip code, calculate Percent_Current_Month as the ratio of Numerator_Count_By_Value over Denominator_Count.STEP 5: Percent zip code for the previous monthRepeat STEP 1 through STEP 4 for the previous month. For each distinct value of zip code, set the percent of zip code for the previous month as Percent_Prior_Month_1. STEP 6: Calculate change between monthsFor each frequency percent, calculate Frequency_Change as the absolute value of (Percent_Current_Month – Percent_Prior_Month_1) / 2. Note that Frequency_Change is a vector of frequencies.STEP 7: Calculate index of dissimilarityCalculate the index of dissimilarity by summing Frequency_Change across all frequencies |
| 10/07/2024 |
3.30.0 |
EL-1-006-4 |
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: Eligible contact information on the last day of 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: Non-missing county code for primary addressOf the MSIS IDs that meet the criteria from STEP 2, further refine the population by keeping records with: 1. ELIGIBLE-COUNTY-CODE non-missing2. ELIGIBLE_ADDRESS_TYPE = "01"STEP 4: Percent eligible county code for the current month1. For each distinct value of county code, set the number of unique MSIS IDs as Numerator_Count_By_Value. 2. Set the total number of unique MSIS IDs across all valid values of county code as Denominator_Count. Note that Denominator_Count should also equal to the count of MSIS IDs from STEP 3. 3. For each distinct value of county code, calculate Percent_Current_Month as the ratio of Numerator_Count_By_Value over Denominator_Count.STEP 5: Percent eligible county code for the previous monthRepeat STEP 1 through STEP 4 for the previous month. For each distinct value of county code, set the percent of county code for the previous month as Percent_Prior_Month_1. STEP 6: Calculate change between monthsFor each frequency percent, calculate Frequency_Change as the absolute value of (Percent_Current_Month – Percent_Prior_Month_1) / 2. Note that Frequency_Change is a vector of frequencies.STEP 7: Calculate index of dissimilarityCalculate the index of dissimilarity by summing Frequency_Change across all frequencies and dividing by 100 |
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 information on the last day of 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: Non-missing county code for primary addressOf the MSIS IDs that meet the criteria from STEP 2, further refine the population by keeping records with: 1. ELIGIBLE-COUNTY-CODE non-missing2. ELIGIBLE_ADDRESS_TYPE = "01"STEP 4: Percent eligible county code for the current month1. For each distinct value of county code, set the number of unique MSIS IDs as Numerator_Count_By_Value. 2. Sum the total number of unique MSIS IDs within each valid value of ethnicity and set as Denominator_Count. Note that Denominator_Count should also equal to the count of MSIS IDs from STEP 3.3. For each distinct value of county code, calculate Percent_Current_Month as the ratio of Numerator_Count_By_Value over Denominator_Count.STEP 5: Percent eligible county code for the previous monthRepeat STEP 1 through STEP 4 for the previous month. For each distinct value of county code, set the percent of county code for the previous month as Percent_Prior_Month_1. STEP 6: Calculate change between monthsFor each frequency percent, calculate Frequency_Change as the absolute value of (Percent_Current_Month – Percent_Prior_Month_1) / 2. Note that Frequency_Change is a vector of frequencies.STEP 7: Calculate index of dissimilarityCalculate the index of dissimilarity by summing Frequency_Change across all frequencies |
| 10/07/2024 |
3.30.0 |
EL-10-001-1 |
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 enrollment on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 1, join to 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: Non-missing plan typeOf the MSIS IDs that meet the criteria from STEP 2, further refine the population by keeping records with: 1. MANAGED-CARE-PLAN-TYPE non-missingSTEP 4: Percent plan type for the current month1. For each distinct value of plan type, set the number of unique MSIS IDs as Numerator_Count_By_Value. 2. Set the total number of unique MSIS IDs across all valid values of plan type as Denominator_Count. Note that Denominator_Count should also equal to the count of MSIS IDs from STEP 3. 3. For each distinct value of plan type, calculate Percent_Current_Month as the ratio of Numerator_Count_By_Value over Denominator_Count. STEP 5: Percent plan type for the previous monthRepeat STEP 1 through STEP 4 for the previous month. For each distinct value of plan type, set the percent of plan type for the previous month as Percent_Prior_Month_1.STEP 6: Calculate change between monthsFor each frequency percent, calculate Frequency_Change as the absolute value of (Percent_Current_Month – Percent_Prior_Month_1) / 2. Note that Frequency_Change is a vector of frequencies.STEP 7: Calculate index of dissimilarityCalculate the index of dissimilarity by summing Frequency_Change across all frequencies and dividing by 100 |
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 enrollment on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 1, join to 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: Non-missing plan typeOf the MSIS IDs that meet the criteria from STEP 2, further refine the population by keeping records with: 1. MANAGED-CARE-PLAN-TYPE non-missingSTEP 4: Percent plan type for the current month1. For each distinct value of plan type, set the number of unique MSIS IDs as Numerator_Count_By_Value. 2. Sum the total number of unique MSIS IDs within each valid value of ethnicity and set as Denominator_Count. Note that Denominator_Count should also equal to the count of MSIS IDs from STEP 3.3. For each distinct value of plan type, calculate Percent_Current_Month as the ratio of Numerator_Count_By_Value over Denominator_Count. STEP 5: Percent plan type for the previous monthRepeat STEP 1 through STEP 4 for the previous month. For each distinct value of plan type, set the percent of plan type for the previous month as Percent_Prior_Month_1.STEP 6: Calculate change between monthsFor each frequency percent, calculate Frequency_Change as the absolute value of (Percent_Current_Month – Percent_Prior_Month_1) / 2. Note that Frequency_Change is a vector of frequencies.STEP 7: Calculate index of dissimilarityCalculate the index of dissimilarity by summing Frequency_Change across all frequencies |
| 10/07/2024 |
3.30.0 |
Data Quality Measures |
UPDATE |
Version text |
3.12.0 |
3.12.1 |
| 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 |
| 02/26/2025 |
3.34.0 |
EL-3-032-41 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EL-3-032-41 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 03/27/2024 |
3.22.0 |
EL-3-032-41 |
ADD |
N/A |
|
Created |
| 02/26/2025 |
3.34.0 |
EL-3-031-40 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EL-3-031-40 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 03/27/2024 |
3.22.0 |
EL-3-031-40 |
ADD |
N/A |
|
Created |
| 02/26/2025 |
3.34.0 |
EL-3-030-39 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EL-3-030-39 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 03/27/2024 |
3.22.0 |
EL-3-030-39 |
ADD |
N/A |
|
Created |
| 02/26/2025 |
3.34.0 |
EL-6-047-47 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EL-6-047-47 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 03/27/2024 |
3.22.0 |
EL-6-047-47 |
ADD |
N/A |
|
Created |
| 02/26/2025 |
3.34.0 |
EL-6-046-46 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EL-6-046-46 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 03/27/2024 |
3.22.0 |
EL-6-046-46 |
ADD |
N/A |
|
Created |
| 02/26/2025 |
3.34.0 |
EL-6-045-45 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EL-6-045-45 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 03/27/2024 |
3.22.0 |
EL-6-045-45 |
ADD |
N/A |
|
Created |
| 02/26/2025 |
3.34.0 |
EL-6-044-44 |
UPDATE |
Priority |
N/A |
Medium |
| 02/26/2025 |
3.34.0 |
EL-6-044-44 |
UPDATE |
Category |
N/A |
Beneficiary eligibility |
| 02/26/2025 |
3.34.0 |
EL-6-044-44 |
UPDATE |
For ta comprehensive |
No |
TA- Inferential |
| 02/26/2025 |
3.34.0 |
EL-6-044-44 |
UPDATE |
For ta inferential |
No |
Yes |
| 02/26/2025 |
3.34.0 |
EL-6-044-44 |
UPDATE |
Ta min |
|
0.001 |
| 02/26/2025 |
3.34.0 |
EL-6-044-44 |
UPDATE |
Ta max |
|
0.7 |
| 02/26/2025 |
3.34.0 |
EL-6-044-44 |
UPDATE |
Threshold minimum |
TBD |
0.001 |
| 02/26/2025 |
3.34.0 |
EL-6-044-44 |
UPDATE |
Threshold maximum |
TBD |
0.7 |
| 03/27/2024 |
3.22.0 |
EL-6-044-44 |
ADD |
N/A |
|
Created |
| 02/26/2025 |
3.34.0 |
EL-6-043-43 |
UPDATE |
Priority |
N/A |
Medium |
| 02/26/2025 |
3.34.0 |
EL-6-043-43 |
UPDATE |
Category |
N/A |
Beneficiary eligibility |
| 02/26/2025 |
3.34.0 |
EL-6-043-43 |
UPDATE |
For ta comprehensive |
No |
TA- Inferential |
| 02/26/2025 |
3.34.0 |
EL-6-043-43 |
UPDATE |
For ta inferential |
No |
Yes |
| 02/26/2025 |
3.34.0 |
EL-6-043-43 |
UPDATE |
Ta min |
|
0.001 |
| 02/26/2025 |
3.34.0 |
EL-6-043-43 |
UPDATE |
Ta max |
|
0.4 |
| 02/26/2025 |
3.34.0 |
EL-6-043-43 |
UPDATE |
Threshold minimum |
TBD |
0.001 |
| 02/26/2025 |
3.34.0 |
EL-6-043-43 |
UPDATE |
Threshold maximum |
TBD |
0.4 |
| 03/27/2024 |
3.22.0 |
EL-6-043-43 |
ADD |
N/A |
|
Created |
| 02/26/2025 |
3.34.0 |
EL-6-042-42 |
UPDATE |
Priority |
N/A |
Medium |
| 02/26/2025 |
3.34.0 |
EL-6-042-42 |
UPDATE |
Category |
N/A |
Beneficiary eligibility |
| 02/26/2025 |
3.34.0 |
EL-6-042-42 |
UPDATE |
For ta comprehensive |
No |
TA- Inferential |
| 02/26/2025 |
3.34.0 |
EL-6-042-42 |
UPDATE |
For ta inferential |
No |
Yes |
| 02/26/2025 |
3.34.0 |
EL-6-042-42 |
UPDATE |
Ta min |
|
0 |
| 02/26/2025 |
3.34.0 |
EL-6-042-42 |
UPDATE |
Ta max |
|
0.05 |
| 02/26/2025 |
3.34.0 |
EL-6-042-42 |
UPDATE |
Threshold minimum |
TBD |
0 |
| 02/26/2025 |
3.34.0 |
EL-6-042-42 |
UPDATE |
Threshold maximum |
TBD |
0.05 |
| 03/27/2024 |
3.22.0 |
EL-6-042-42 |
ADD |
N/A |
|
Created |
| 02/26/2025 |
3.34.0 |
EL-6-040-40 |
UPDATE |
Priority |
N/A |
High |
| 02/26/2025 |
3.34.0 |
EL-6-040-40 |
UPDATE |
Category |
N/A |
Beneficiary eligibility |
| 02/26/2025 |
3.34.0 |
EL-6-040-40 |
UPDATE |
For ta comprehensive |
No |
TA- Inferential |
| 02/26/2025 |
3.34.0 |
EL-6-040-40 |
UPDATE |
For ta inferential |
No |
Yes |
| 02/26/2025 |
3.34.0 |
EL-6-040-40 |
UPDATE |
Ta min |
|
0.001 |
| 02/26/2025 |
3.34.0 |
EL-6-040-40 |
UPDATE |
Ta max |
|
0.1 |
| 02/26/2025 |
3.34.0 |
EL-6-040-40 |
UPDATE |
Threshold minimum |
TBD |
0.001 |
| 02/26/2025 |
3.34.0 |
EL-6-040-40 |
UPDATE |
Threshold maximum |
TBD |
0.1 |
| 02/26/2025 |
3.34.0 |
EL-6-040-40 |
UPDATE |
Annotation |
N/A |
Calculate the percentage of MSIS IDs enrolled in the past 12 months with at least one gap in enrollment during that time period |
| 02/26/2025 |
3.34.0 |
EL-6-040-40 |
UPDATE |
Specification |
N/A |
STEP 1: Enrolled at any time within the past 12 monthsDefine 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 >= 12 months prior to last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Enrollment Type is Medicaid or CHIPUsing the MSIS IDs that meet the criteria from STEP 1, further refine the population by keeping records with: 1. ENROLLMENT-TYPE = "1" or "2"STEP 3: Enrollment status by monthUsing the MSIS IDs that meet the criteria from STEP 2, for each month within the 12 month period identified in STEP 1, set Enrollment_Status = "1" where:1. ENROLLMENT-EFF-DATE <= first day of the month 2. ENROLLMENT-END-DATE >= last day of the month OR missingELSESet Enrollment_Status = "0"STEP 4: Identify enrollment gapsFor each month within the 12 month period identified in STEP 1, set Enrollment_Gap = "1" where:1. Enrollment_Status = "0" for the month2. There is any prior month within the 12 month period with Enrollment_Status = "1"3. There is any subsequent month within the 12 month period with Enrollment_Status = "1"ELSESet Enrollment_Gap = "0"STEP 5: Address multi-month enrollment gaps by keeping the enrollment gap status only for the earliest monthFor the months identified in STEP 4 where Enrollment_Status = "1", if the preceding month in the 12 month period also has Enrollment_Status = "1", set Enrollment_Status for the month = "0" STEP 6: Total count of enrollment gaps across 12 month periodFor each MSIS ID that meets the criteria from STEP 2, set Gap_Total = Count of months where Enrollment_Gap = "1"STEP 7: Count of MSIS IDs with an enrollment gapFor each MSIS ID that meets the criteria from STEP 2, further refine the population by keeping records where Gap_Total is greater than 0STEP 8: Calculate percentage for measureDivide the count of MSIS IDs from STEP 6 by the count of MSIS IDs from STEP 2 |
| 02/26/2025 |
3.34.0 |
EL-6-040-40 |
UPDATE |
Focus area |
N/A |
Enrollment monitoring |
| 03/27/2024 |
3.22.0 |
EL-6-040-40 |
ADD |
N/A |
|
Created |
| 02/26/2025 |
3.34.0 |
EL-6-039-39 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EL-6-039-39 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 03/27/2024 |
3.22.0 |
EL-6-039-39 |
ADD |
N/A |
|
Created |
| 02/26/2025 |
3.34.0 |
EL-6-038-38 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EL-6-038-38 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 03/27/2024 |
3.22.0 |
EL-6-038-38 |
ADD |
N/A |
|
Created |
| 02/26/2025 |
3.34.0 |
ALL-16-023-23 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
ALL-16-023-23 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 03/27/2024 |
3.22.0 |
ALL-16-023-23 |
ADD |
N/A |
|
Created |
| 02/26/2025 |
3.34.0 |
ALL-16-022-22 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
ALL-16-022-22 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 03/27/2024 |
3.22.0 |
ALL-16-022-22 |
ADD |
N/A |
|
Created |
| 02/26/2025 |
3.34.0 |
ALL-16-021-21 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
ALL-16-021-21 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 03/27/2024 |
3.22.0 |
ALL-16-021-21 |
ADD |
N/A |
|
Created |
| 02/26/2025 |
3.34.0 |
ALL-16-020-20 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
ALL-16-020-20 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 03/27/2024 |
3.22.0 |
ALL-16-020-20 |
ADD |
N/A |
|
Created |
| 02/26/2025 |
3.34.0 |
ALL-16-019-19 |
UPDATE |
Measure name |
% of claims with IHS-SERVICE-IND = “1” (RX) not linked to any MSIS ID where AMERICAN-INDIAN-ALASKAN-NATIVE-INDICATOR = “1” |
% of claims with IHS-SERVICE-IND = “1” not linked to any MSIS ID where AMERICAN-INDIAN-ALASKAN-NATIVE-INDICATOR = “1” |
| 02/26/2025 |
3.34.0 |
ALL-16-019-19 |
UPDATE |
Priority |
N/A |
Medium |
| 02/26/2025 |
3.34.0 |
ALL-16-019-19 |
UPDATE |
Category |
N/A |
Utilization |
| 02/26/2025 |
3.34.0 |
ALL-16-019-19 |
UPDATE |
For ta comprehensive |
No |
TA- Inferential |
| 02/26/2025 |
3.34.0 |
ALL-16-019-19 |
UPDATE |
For ta inferential |
No |
Yes |
| 02/26/2025 |
3.34.0 |
ALL-16-019-19 |
UPDATE |
Ta min |
|
0 |
| 02/26/2025 |
3.34.0 |
ALL-16-019-19 |
UPDATE |
Ta max |
|
0.1 |
| 02/26/2025 |
3.34.0 |
ALL-16-019-19 |
UPDATE |
Threshold minimum |
TBD |
0 |
| 02/26/2025 |
3.34.0 |
ALL-16-019-19 |
UPDATE |
Threshold maximum |
TBD |
0.1 |
| 03/27/2024 |
3.22.0 |
ALL-16-019-19 |
ADD |
N/A |
|
Created |
| 02/26/2025 |
3.34.0 |
ALL-16-018-18 |
UPDATE |
Measure name |
% of claims with IHS-SERVICE-IND = “1” (OT) not linked to any MSIS ID where AMERICAN-INDIAN-ALASKAN-NATIVE-INDICATOR = “1” |
% of claims with IHS-SERVICE-IND = “1” not linked to any MSIS ID where AMERICAN-INDIAN-ALASKAN-NATIVE-INDICATOR = “1” |
| 02/26/2025 |
3.34.0 |
ALL-16-018-18 |
UPDATE |
Priority |
N/A |
Medium |
| 02/26/2025 |
3.34.0 |
ALL-16-018-18 |
UPDATE |
Category |
N/A |
Utilization |
| 02/26/2025 |
3.34.0 |
ALL-16-018-18 |
UPDATE |
For ta comprehensive |
No |
TA- Inferential |
| 02/26/2025 |
3.34.0 |
ALL-16-018-18 |
UPDATE |
For ta inferential |
No |
Yes |
| 02/26/2025 |
3.34.0 |
ALL-16-018-18 |
UPDATE |
Ta min |
|
0 |
| 02/26/2025 |
3.34.0 |
ALL-16-018-18 |
UPDATE |
Ta max |
|
0.1 |
| 02/26/2025 |
3.34.0 |
ALL-16-018-18 |
UPDATE |
Threshold minimum |
TBD |
0 |
| 02/26/2025 |
3.34.0 |
ALL-16-018-18 |
UPDATE |
Threshold maximum |
TBD |
0.1 |
| 03/27/2024 |
3.22.0 |
ALL-16-018-18 |
ADD |
N/A |
|
Created |
| 02/26/2025 |
3.34.0 |
ALL-16-017-17 |
UPDATE |
Measure name |
% of claims with IHS-SERVICE-IND = “1” (LT) not linked to any MSIS ID where AMERICAN-INDIAN-ALASKAN-NATIVE-INDICATOR = “1” |
% of claims with IHS-SERVICE-IND = “1” not linked to any MSIS ID where AMERICAN-INDIAN-ALASKAN-NATIVE-INDICATOR = “1” |
| 02/26/2025 |
3.34.0 |
ALL-16-017-17 |
UPDATE |
Priority |
N/A |
Medium |
| 02/26/2025 |
3.34.0 |
ALL-16-017-17 |
UPDATE |
Category |
N/A |
Utilization |
| 02/26/2025 |
3.34.0 |
ALL-16-017-17 |
UPDATE |
For ta comprehensive |
No |
TA- Inferential |
| 02/26/2025 |
3.34.0 |
ALL-16-017-17 |
UPDATE |
For ta inferential |
No |
Yes |
| 02/26/2025 |
3.34.0 |
ALL-16-017-17 |
UPDATE |
Ta min |
|
0 |
| 02/26/2025 |
3.34.0 |
ALL-16-017-17 |
UPDATE |
Ta max |
|
0.1 |
| 02/26/2025 |
3.34.0 |
ALL-16-017-17 |
UPDATE |
Threshold minimum |
TBD |
0 |
| 02/26/2025 |
3.34.0 |
ALL-16-017-17 |
UPDATE |
Threshold maximum |
TBD |
0.1 |
| 03/27/2024 |
3.22.0 |
ALL-16-017-17 |
ADD |
N/A |
|
Created |
| 02/26/2025 |
3.34.0 |
ALL-16-016-16 |
UPDATE |
Measure name |
% of claims with IHS-SERVICE-IND = “1” (IP) not linked to any MSIS ID where AMERICAN-INDIAN-ALASKAN-NATIVE-INDICATOR = “1” |
% of claims with IHS-SERVICE-IND = “1” not linked to any MSIS ID where AMERICAN-INDIAN-ALASKAN-NATIVE-INDICATOR = “1” |
| 02/26/2025 |
3.34.0 |
ALL-16-016-16 |
UPDATE |
Priority |
N/A |
Medium |
| 02/26/2025 |
3.34.0 |
ALL-16-016-16 |
UPDATE |
Category |
N/A |
Utilization |
| 02/26/2025 |
3.34.0 |
ALL-16-016-16 |
UPDATE |
For ta comprehensive |
No |
TA- Inferential |
| 02/26/2025 |
3.34.0 |
ALL-16-016-16 |
UPDATE |
For ta inferential |
No |
Yes |
| 02/26/2025 |
3.34.0 |
ALL-16-016-16 |
UPDATE |
Ta min |
|
0 |
| 02/26/2025 |
3.34.0 |
ALL-16-016-16 |
UPDATE |
Ta max |
|
0.1 |
| 02/26/2025 |
3.34.0 |
ALL-16-016-16 |
UPDATE |
Threshold minimum |
TBD |
0 |
| 02/26/2025 |
3.34.0 |
ALL-16-016-16 |
UPDATE |
Threshold maximum |
TBD |
0.1 |
| 03/27/2024 |
3.22.0 |
ALL-16-016-16 |
ADD |
N/A |
|
Created |
| 02/26/2025 |
3.34.0 |
MIS-6-024_43 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
MIS-6-024_43 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 03/27/2024 |
3.22.0 |
MIS-6-024_43 |
ADD |
N/A |
|
Created |
| 02/26/2025 |
3.34.0 |
MIS-6-024_42 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
MIS-6-024_42 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 03/27/2024 |
3.22.0 |
MIS-6-024_42 |
ADD |
N/A |
|
Created |
| 10/07/2024 |
3.30.0 |
RULE-7379 |
UPDATE |
Adjustment type |
Original and Replacement |
Non-void |
| 10/07/2024 |
3.30.0 |
RULE-7378 |
UPDATE |
Adjustment type |
Original and Replacement |
Non-void |
| 10/07/2024 |
3.30.0 |
RULE-7377 |
UPDATE |
Adjustment type |
Original and Replacement |
Non-void |
| 10/07/2024 |
3.30.0 |
RULE-7376 |
UPDATE |
Adjustment type |
Original and Replacement |
Non-void |
| 10/07/2024 |
3.30.0 |
RULE-7375 |
UPDATE |
Adjustment type |
Original and Replacement |
Non-void |
| 10/07/2024 |
3.30.0 |
RULE-7374 |
UPDATE |
Adjustment type |
Original and Replacement |
Non-void |
| 10/07/2024 |
3.30.0 |
RULE-7373 |
UPDATE |
Adjustment type |
Original and Replacement |
Non-void |
| 10/07/2024 |
3.30.0 |
RULE-7372 |
UPDATE |
Adjustment type |
Original and Replacement |
Non-void |
| 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 |
| 12/18/2024 |
3.33.0 |
RULE-7370 |
UPDATE |
Focus area |
Unwinding |
Enrollment monitoring |
| 12/18/2024 |
3.33.0 |
RULE-7366 |
UPDATE |
Focus area |
Unwinding |
Enrollment monitoring |
| 12/18/2024 |
3.33.0 |
RULE-7423 |
UPDATE |
Focus area |
Unwinding |
Enrollment monitoring |
| 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 |
| 12/18/2024 |
3.33.0 |
EL-3-019_1-34 |
UPDATE |
Focus area |
Unwinding |
Enrollment monitoring |
| 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 |
| 12/18/2024 |
3.33.0 |
RULE-7447 |
UPDATE |
Focus area |
Unwinding |
Enrollment monitoring |
| 12/18/2024 |
3.33.0 |
RULE-2135 |
UPDATE |
Focus area |
Unwinding |
Enrollment monitoring |
| 12/18/2024 |
3.33.0 |
EL-3-017-22 |
UPDATE |
Focus area |
Unwinding |
Enrollment monitoring |
| 12/18/2024 |
3.33.0 |
EL-15-002-2 |
UPDATE |
Focus area |
Unwinding |
Enrollment monitoring |
| 12/18/2024 |
3.33.0 |
EL-15-001-1 |
UPDATE |
Focus area |
Unwinding |
Enrollment monitoring |
| 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 |
| 02/26/2025 |
3.34.0 |
MCR-19-006-4 |
UPDATE |
Priority |
N/A |
Medium |
| 02/26/2025 |
3.34.0 |
MCR-19-006-4 |
UPDATE |
Category |
N/A |
Utilization |
| 02/26/2025 |
3.34.0 |
MCR-19-006-4 |
UPDATE |
For ta comprehensive |
No |
TA- Inferential |
| 02/26/2025 |
3.34.0 |
MCR-19-006-4 |
UPDATE |
For ta inferential |
No |
Yes |
| 02/26/2025 |
3.34.0 |
MCR-19-006-4 |
UPDATE |
Ta min |
|
0 |
| 02/26/2025 |
3.34.0 |
MCR-19-006-4 |
UPDATE |
Ta max |
|
0.2 |
| 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 |
| 02/26/2025 |
3.34.0 |
MCR-14-024-2 |
UPDATE |
Priority |
N/A |
Medium |
| 02/26/2025 |
3.34.0 |
MCR-14-024-2 |
UPDATE |
Category |
N/A |
Utilization |
| 02/26/2025 |
3.34.0 |
MCR-14-024-2 |
UPDATE |
For ta comprehensive |
No |
TA- Inferential |
| 02/26/2025 |
3.34.0 |
MCR-14-024-2 |
UPDATE |
For ta inferential |
No |
Yes |
| 02/26/2025 |
3.34.0 |
MCR-14-024-2 |
UPDATE |
Ta min |
|
0.4 |
| 02/26/2025 |
3.34.0 |
MCR-14-024-2 |
UPDATE |
Ta max |
|
0.99 |
| 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 |
|
| 02/26/2025 |
3.34.0 |
FFS-16-007-4 |
UPDATE |
Priority |
N/A |
Medium |
| 02/26/2025 |
3.34.0 |
FFS-16-007-4 |
UPDATE |
Category |
N/A |
Utilization |
| 02/26/2025 |
3.34.0 |
FFS-16-007-4 |
UPDATE |
For ta comprehensive |
No |
TA- Inferential |
| 02/26/2025 |
3.34.0 |
FFS-16-007-4 |
UPDATE |
For ta inferential |
No |
Yes |
| 02/26/2025 |
3.34.0 |
FFS-16-007-4 |
UPDATE |
Ta min |
|
0 |
| 02/26/2025 |
3.34.0 |
FFS-16-007-4 |
UPDATE |
Ta max |
|
0.2 |
| 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 |
|
| 02/26/2025 |
3.34.0 |
FFS-11-024-2 |
UPDATE |
Priority |
N/A |
Medium |
| 02/26/2025 |
3.34.0 |
FFS-11-024-2 |
UPDATE |
Category |
N/A |
Utilization |
| 02/26/2025 |
3.34.0 |
FFS-11-024-2 |
UPDATE |
For ta comprehensive |
No |
TA- Inferential |
| 02/26/2025 |
3.34.0 |
FFS-11-024-2 |
UPDATE |
For ta inferential |
No |
Yes |
| 02/26/2025 |
3.34.0 |
FFS-11-024-2 |
UPDATE |
Ta min |
|
0.4 |
| 02/26/2025 |
3.34.0 |
FFS-11-024-2 |
UPDATE |
Ta max |
|
0.99 |
| 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 |
| 12/18/2024 |
3.33.0 |
RULE-7460 |
UPDATE |
Priority |
High |
N/A |
| 12/18/2024 |
3.33.0 |
RULE-7460 |
UPDATE |
Category |
Utilization |
N/A |
| 12/18/2024 |
3.33.0 |
RULE-7460 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 12/18/2024 |
3.33.0 |
RULE-7460 |
UPDATE |
For ta inferential |
Yes |
No |
| 12/18/2024 |
3.33.0 |
RULE-7460 |
UPDATE |
Ta min |
0 |
|
| 12/18/2024 |
3.33.0 |
RULE-7460 |
UPDATE |
Ta max |
0.001 |
|
| 12/18/2024 |
3.33.0 |
RULE-7446 |
UPDATE |
Priority |
High |
N/A |
| 12/18/2024 |
3.33.0 |
RULE-7446 |
UPDATE |
Category |
Provider enrollment |
N/A |
| 12/18/2024 |
3.33.0 |
RULE-7446 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 12/18/2024 |
3.33.0 |
RULE-7446 |
UPDATE |
For ta inferential |
Yes |
No |
| 12/18/2024 |
3.33.0 |
RULE-7446 |
UPDATE |
Ta min |
0 |
|
| 12/18/2024 |
3.33.0 |
RULE-7446 |
UPDATE |
Ta max |
0.05 |
|
| 12/18/2024 |
3.33.0 |
RULE-7445 |
UPDATE |
Priority |
High |
N/A |
| 12/18/2024 |
3.33.0 |
RULE-7445 |
UPDATE |
Category |
Provider enrollment |
N/A |
| 12/18/2024 |
3.33.0 |
RULE-7445 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 12/18/2024 |
3.33.0 |
RULE-7445 |
UPDATE |
For ta inferential |
Yes |
No |
| 12/18/2024 |
3.33.0 |
RULE-7445 |
UPDATE |
Ta min |
0 |
|
| 12/18/2024 |
3.33.0 |
RULE-7445 |
UPDATE |
Ta max |
0.05 |
|
| 12/18/2024 |
3.33.0 |
RULE-7444 |
UPDATE |
Priority |
High |
N/A |
| 12/18/2024 |
3.33.0 |
RULE-7444 |
UPDATE |
Category |
Provider enrollment |
N/A |
| 12/18/2024 |
3.33.0 |
RULE-7444 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 12/18/2024 |
3.33.0 |
RULE-7444 |
UPDATE |
For ta inferential |
Yes |
No |
| 12/18/2024 |
3.33.0 |
RULE-7444 |
UPDATE |
Ta min |
0 |
|
| 12/18/2024 |
3.33.0 |
RULE-7444 |
UPDATE |
Ta max |
0.05 |
|
| 12/18/2024 |
3.33.0 |
RULE-7443 |
UPDATE |
Priority |
High |
N/A |
| 12/18/2024 |
3.33.0 |
RULE-7443 |
UPDATE |
Category |
Provider enrollment |
N/A |
| 12/18/2024 |
3.33.0 |
RULE-7443 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 12/18/2024 |
3.33.0 |
RULE-7443 |
UPDATE |
For ta inferential |
Yes |
No |
| 12/18/2024 |
3.33.0 |
RULE-7443 |
UPDATE |
Ta min |
0 |
|
| 12/18/2024 |
3.33.0 |
RULE-7443 |
UPDATE |
Ta max |
0.05 |
|
| 12/18/2024 |
3.33.0 |
RULE-7442 |
UPDATE |
Priority |
High |
N/A |
| 12/18/2024 |
3.33.0 |
RULE-7442 |
UPDATE |
Category |
Provider enrollment |
N/A |
| 12/18/2024 |
3.33.0 |
RULE-7442 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 12/18/2024 |
3.33.0 |
RULE-7442 |
UPDATE |
For ta inferential |
Yes |
No |
| 12/18/2024 |
3.33.0 |
RULE-7442 |
UPDATE |
Ta min |
0 |
|
| 12/18/2024 |
3.33.0 |
RULE-7442 |
UPDATE |
Ta max |
0.05 |
|
| 12/18/2024 |
3.33.0 |
RULE-7441 |
UPDATE |
Priority |
High |
N/A |
| 12/18/2024 |
3.33.0 |
RULE-7441 |
UPDATE |
Category |
Provider enrollment |
N/A |
| 12/18/2024 |
3.33.0 |
RULE-7441 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 12/18/2024 |
3.33.0 |
RULE-7441 |
UPDATE |
For ta inferential |
Yes |
No |
| 12/18/2024 |
3.33.0 |
RULE-7441 |
UPDATE |
Ta min |
0 |
|
| 12/18/2024 |
3.33.0 |
RULE-7441 |
UPDATE |
Ta max |
0.05 |
|
| 12/18/2024 |
3.33.0 |
RULE-7440 |
UPDATE |
Priority |
High |
N/A |
| 12/18/2024 |
3.33.0 |
RULE-7440 |
UPDATE |
Category |
Provider enrollment |
N/A |
| 12/18/2024 |
3.33.0 |
RULE-7440 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 12/18/2024 |
3.33.0 |
RULE-7440 |
UPDATE |
For ta inferential |
Yes |
No |
| 12/18/2024 |
3.33.0 |
RULE-7440 |
UPDATE |
Ta min |
0 |
|
| 12/18/2024 |
3.33.0 |
RULE-7440 |
UPDATE |
Ta max |
0.05 |
|
| 12/18/2024 |
3.33.0 |
RULE-7439 |
UPDATE |
Priority |
High |
N/A |
| 12/18/2024 |
3.33.0 |
RULE-7439 |
UPDATE |
Category |
Provider enrollment |
N/A |
| 12/18/2024 |
3.33.0 |
RULE-7439 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 12/18/2024 |
3.33.0 |
RULE-7439 |
UPDATE |
For ta inferential |
Yes |
No |
| 12/18/2024 |
3.33.0 |
RULE-7439 |
UPDATE |
Ta min |
0 |
|
| 12/18/2024 |
3.33.0 |
RULE-7439 |
UPDATE |
Ta max |
0.05 |
|
| 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 |
| 10/07/2024 |
3.30.0 |
RULE-7646 |
UPDATE |
Priority |
Critical |
High |
| 10/07/2024 |
3.30.0 |
RULE-7645 |
UPDATE |
Priority |
Critical |
High |
| 10/07/2024 |
3.30.0 |
RULE-7644 |
UPDATE |
Priority |
Critical |
High |
| 10/07/2024 |
3.30.0 |
RULE-7643 |
UPDATE |
Priority |
Critical |
High |
| 10/07/2024 |
3.30.0 |
RULE-7642 |
UPDATE |
Priority |
Critical |
High |
| 02/02/2024 |
3.18.0 |
EL-3-019_1-34 |
UPDATE |
Focus area |
N/A |
Unwinding |
| 10/07/2024 |
3.30.0 |
RULE-7522 |
UPDATE |
Adjustment type |
All Adjustment Types |
Non-void |
| 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 |
| 12/18/2024 |
3.33.0 |
MIS-85-021-21 |
UPDATE |
Priority |
Medium |
High |
| 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 |
| 12/18/2024 |
3.33.0 |
MIS-27-021-21 |
UPDATE |
Priority |
Medium |
High |
| 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 |
| 10/07/2024 |
3.30.0 |
RULE-7536 |
UPDATE |
Adjustment type |
Original and Replacement |
Non-void |
| 10/07/2024 |
3.30.0 |
RULE-7535 |
UPDATE |
Adjustment type |
Original and Replacement |
Non-void |
| 10/07/2024 |
3.30.0 |
RULE-7533 |
UPDATE |
Adjustment type |
Original and Replacement |
Non-void |
| 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 |
| 02/26/2025 |
3.34.0 |
RULE-2810 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 02/26/2025 |
3.34.0 |
RULE-2810 |
UPDATE |
For ta inferential |
Yes |
No |
| 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 |
MCR-60-008-8 |
UPDATE |
Specification |
STEP 1: Active non-duplicate paid RX claims during 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 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 = "3"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-60-008-8 |
UPDATE |
Focus area |
Managed care |
N/A |
| 06/19/2024 |
3.27.0 |
MCR-60-007-7 |
UPDATE |
Priority |
High |
N/A |
| 06/19/2024 |
3.27.0 |
MCR-60-007-7 |
UPDATE |
Category |
Provider information |
N/A |
| 06/19/2024 |
3.27.0 |
MCR-60-007-7 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 06/19/2024 |
3.27.0 |
MCR-60-007-7 |
UPDATE |
For ta inferential |
Yes |
No |
| 06/19/2024 |
3.27.0 |
MCR-60-007-7 |
UPDATE |
Ta min |
0 |
|
| 06/19/2024 |
3.27.0 |
MCR-60-007-7 |
UPDATE |
Ta max |
0.01 |
|
| 06/19/2024 |
3.27.0 |
MCR-60-007-7 |
UPDATE |
Annotation |
Calculate the percentage Medicaid Encounter: original and adjustment, paid OT claims with an invalid billing provider NPI number |
N/A |
| 06/19/2024 |
3.27.0 |
MCR-60-007-7 |
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: Medicaid 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 = "3"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-60-007-7 |
UPDATE |
Focus area |
Managed care |
N/A |
| 06/19/2024 |
3.27.0 |
MCR-60-006-6 |
UPDATE |
Priority |
High |
N/A |
| 06/19/2024 |
3.27.0 |
MCR-60-006-6 |
UPDATE |
Category |
Provider information |
N/A |
| 06/19/2024 |
3.27.0 |
MCR-60-006-6 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 06/19/2024 |
3.27.0 |
MCR-60-006-6 |
UPDATE |
For ta inferential |
Yes |
No |
| 06/19/2024 |
3.27.0 |
MCR-60-006-6 |
UPDATE |
Ta min |
0 |
|
| 06/19/2024 |
3.27.0 |
MCR-60-006-6 |
UPDATE |
Ta max |
0.01 |
|
| 06/19/2024 |
3.27.0 |
MCR-60-006-6 |
UPDATE |
Annotation |
Calculate the percentage Medicaid Encounter: original and adjustment, paid LT claims with an invalid billing provider NPI number |
N/A |
| 06/19/2024 |
3.27.0 |
MCR-60-006-6 |
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: Medicaid 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 = "3"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-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-60-006-6 |
UPDATE |
Focus area |
Managed care |
N/A |
| 06/19/2024 |
3.27.0 |
MCR-60-005-5 |
UPDATE |
Priority |
High |
N/A |
| 06/19/2024 |
3.27.0 |
MCR-60-005-5 |
UPDATE |
Category |
Provider information |
N/A |
| 06/19/2024 |
3.27.0 |
MCR-60-005-5 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 06/19/2024 |
3.27.0 |
MCR-60-005-5 |
UPDATE |
For ta inferential |
Yes |
No |
| 06/19/2024 |
3.27.0 |
MCR-60-005-5 |
UPDATE |
Ta min |
0 |
|
| 06/19/2024 |
3.27.0 |
MCR-60-005-5 |
UPDATE |
Ta max |
0.01 |
|
| 06/19/2024 |
3.27.0 |
MCR-60-005-5 |
UPDATE |
Annotation |
Calculate the percentage Medicaid Encounter: original and adjustment, paid IP claims with an invalid billing provider NPI number |
N/A |
| 06/19/2024 |
3.27.0 |
MCR-60-005-5 |
UPDATE |
Specification |
STEP 1: Active non-duplicate IP paid 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-INDSTEP 2: Medicaid 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 = "3"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-60-005-5 |
UPDATE |
Focus area |
Managed care |
N/A |
| 06/19/2024 |
3.27.0 |
MCR-60-003-3 |
UPDATE |
Priority |
High |
N/A |
| 06/19/2024 |
3.27.0 |
MCR-60-003-3 |
UPDATE |
Category |
Provider information |
N/A |
| 06/19/2024 |
3.27.0 |
MCR-60-003-3 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 06/19/2024 |
3.27.0 |
MCR-60-003-3 |
UPDATE |
For ta inferential |
Yes |
No |
| 06/19/2024 |
3.27.0 |
MCR-60-003-3 |
UPDATE |
Ta min |
0 |
|
| 06/19/2024 |
3.27.0 |
MCR-60-003-3 |
UPDATE |
Ta max |
0.05 |
|
| 06/19/2024 |
3.27.0 |
MCR-60-003-3 |
UPDATE |
Annotation |
Calculate the percentage of Medicaid 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-60-003-3 |
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: Medicaid 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 = "3"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-60-003-3 |
UPDATE |
Focus area |
Managed care |
N/A |
| 06/19/2024 |
3.27.0 |
MCR-60-002-2 |
UPDATE |
Priority |
High |
N/A |
| 06/19/2024 |
3.27.0 |
MCR-60-002-2 |
UPDATE |
Category |
Provider information |
N/A |
| 06/19/2024 |
3.27.0 |
MCR-60-002-2 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 06/19/2024 |
3.27.0 |
MCR-60-002-2 |
UPDATE |
For ta inferential |
Yes |
No |
| 06/19/2024 |
3.27.0 |
MCR-60-002-2 |
UPDATE |
Ta min |
0 |
|
| 06/19/2024 |
3.27.0 |
MCR-60-002-2 |
UPDATE |
Ta max |
0.05 |
|
| 06/19/2024 |
3.27.0 |
MCR-60-002-2 |
UPDATE |
Annotation |
Calculate the percentage of Medicaid 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-60-002-2 |
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: Medicaid 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 = "3"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-60-002-2 |
UPDATE |
Focus area |
Managed care |
N/A |
| 06/19/2024 |
3.27.0 |
MCR-60-001-1 |
UPDATE |
Priority |
High |
N/A |
| 06/19/2024 |
3.27.0 |
MCR-60-001-1 |
UPDATE |
Category |
Provider information |
N/A |
| 06/19/2024 |
3.27.0 |
MCR-60-001-1 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 06/19/2024 |
3.27.0 |
MCR-60-001-1 |
UPDATE |
For ta inferential |
Yes |
No |
| 06/19/2024 |
3.27.0 |
MCR-60-001-1 |
UPDATE |
Ta min |
0 |
|
| 06/19/2024 |
3.27.0 |
MCR-60-001-1 |
UPDATE |
Ta max |
0.05 |
|
| 06/19/2024 |
3.27.0 |
MCR-60-001-1 |
UPDATE |
Annotation |
Calculate the percentage of Medicaid 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-60-001-1 |
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: Medicaid 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 = "3"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-60-001-1 |
UPDATE |
Focus area |
Managed care |
N/A |
| 06/19/2024 |
3.27.0 |
FFS-51-008-8 |
UPDATE |
Priority |
High |
N/A |
| 06/19/2024 |
3.27.0 |
FFS-51-008-8 |
UPDATE |
Category |
Provider information |
N/A |
| 06/19/2024 |
3.27.0 |
FFS-51-008-8 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 06/19/2024 |
3.27.0 |
FFS-51-008-8 |
UPDATE |
For ta inferential |
Yes |
No |
| 06/19/2024 |
3.27.0 |
FFS-51-008-8 |
UPDATE |
Ta min |
0 |
|
| 06/19/2024 |
3.27.0 |
FFS-51-008-8 |
UPDATE |
Ta max |
0.01 |
|
| 06/19/2024 |
3.27.0 |
FFS-51-008-8 |
UPDATE |
Annotation |
Calculate the percentage S-CHIP FFS: original and adjustment, paid RX claims with an invalid billing provider NPI number |
N/A |
| 06/19/2024 |
3.27.0 |
FFS-51-008-8 |
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 FFS: 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 = "A"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 |
FFS-51-007-7 |
UPDATE |
Priority |
High |
N/A |
| 06/19/2024 |
3.27.0 |
FFS-51-007-7 |
UPDATE |
Category |
Provider information |
N/A |
| 06/19/2024 |
3.27.0 |
FFS-51-007-7 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 06/19/2024 |
3.27.0 |
FFS-51-007-7 |
UPDATE |
For ta inferential |
Yes |
No |
| 06/19/2024 |
3.27.0 |
FFS-51-007-7 |
UPDATE |
Ta min |
0 |
|
| 06/19/2024 |
3.27.0 |
FFS-51-007-7 |
UPDATE |
Ta max |
0.01 |
|
| 06/19/2024 |
3.27.0 |
FFS-51-007-7 |
UPDATE |
Annotation |
Calculate the percentage S-CHIP FFS: original and adjustment, paid OT claims with an invalid billing provider NPI number |
N/A |
| 06/19/2024 |
3.27.0 |
FFS-51-007-7 |
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 FFS: 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 = "A"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 |
FFS-51-006-6 |
UPDATE |
Priority |
High |
N/A |
| 06/19/2024 |
3.27.0 |
FFS-51-006-6 |
UPDATE |
Category |
Provider information |
N/A |
| 06/19/2024 |
3.27.0 |
FFS-51-006-6 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 06/19/2024 |
3.27.0 |
FFS-51-006-6 |
UPDATE |
For ta inferential |
Yes |
No |
| 06/19/2024 |
3.27.0 |
FFS-51-006-6 |
UPDATE |
Ta min |
0 |
|
| 06/19/2024 |
3.27.0 |
FFS-51-006-6 |
UPDATE |
Ta max |
0.01 |
|
| 06/19/2024 |
3.27.0 |
FFS-51-006-6 |
UPDATE |
Annotation |
Calculate the percentage S-CHIP FFS: original and adjustment, paid LT claims with an invalid billing provider NPI number |
N/A |
| 06/19/2024 |
3.27.0 |
FFS-51-006-6 |
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 FFS: 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 = "A"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 |
FFS-51-005-5 |
UPDATE |
Priority |
High |
N/A |
| 06/19/2024 |
3.27.0 |
FFS-51-005-5 |
UPDATE |
Category |
Provider information |
N/A |
| 06/19/2024 |
3.27.0 |
FFS-51-005-5 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 06/19/2024 |
3.27.0 |
FFS-51-005-5 |
UPDATE |
For ta inferential |
Yes |
No |
| 06/19/2024 |
3.27.0 |
FFS-51-005-5 |
UPDATE |
Ta min |
0 |
|
| 06/19/2024 |
3.27.0 |
FFS-51-005-5 |
UPDATE |
Ta max |
0.01 |
|
| 06/19/2024 |
3.27.0 |
FFS-51-005-5 |
UPDATE |
Annotation |
Calculate the percentage S-CHIP FFS: original and adjustment, paid IP claims with an invalid billing provider NPI number |
N/A |
| 06/19/2024 |
3.27.0 |
FFS-51-005-5 |
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 FFS: 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 = "A"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 |
FFS-51-003-3 |
UPDATE |
Priority |
High |
N/A |
| 06/19/2024 |
3.27.0 |
FFS-51-003-3 |
UPDATE |
Category |
Provider information |
N/A |
| 06/19/2024 |
3.27.0 |
FFS-51-003-3 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 06/19/2024 |
3.27.0 |
FFS-51-003-3 |
UPDATE |
For ta inferential |
Yes |
No |
| 06/19/2024 |
3.27.0 |
FFS-51-003-3 |
UPDATE |
Ta min |
0 |
|
| 06/19/2024 |
3.27.0 |
FFS-51-003-3 |
UPDATE |
Ta max |
0.05 |
|
| 06/19/2024 |
3.27.0 |
FFS-51-003-3 |
UPDATE |
Annotation |
Calculate the percentage of S-CHIP FFS: 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 |
FFS-51-003-3 |
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 FFS: 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 = "A"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 |
FFS-51-002-2 |
UPDATE |
Priority |
High |
N/A |
| 06/19/2024 |
3.27.0 |
FFS-51-002-2 |
UPDATE |
Category |
Provider information |
N/A |
| 06/19/2024 |
3.27.0 |
FFS-51-002-2 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 06/19/2024 |
3.27.0 |
FFS-51-002-2 |
UPDATE |
For ta inferential |
Yes |
No |
| 06/19/2024 |
3.27.0 |
FFS-51-002-2 |
UPDATE |
Ta min |
0 |
|
| 06/19/2024 |
3.27.0 |
FFS-51-002-2 |
UPDATE |
Ta max |
0.05 |
|
| 06/19/2024 |
3.27.0 |
FFS-51-002-2 |
UPDATE |
Annotation |
Calculate the percentage of S-CHIP FFS: 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 |
FFS-51-002-2 |
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 FFS: 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 = "A"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 |
FFS-51-001-1 |
UPDATE |
Priority |
High |
N/A |
| 06/19/2024 |
3.27.0 |
FFS-51-001-1 |
UPDATE |
Category |
Provider information |
N/A |
| 06/19/2024 |
3.27.0 |
FFS-51-001-1 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 06/19/2024 |
3.27.0 |
FFS-51-001-1 |
UPDATE |
For ta inferential |
Yes |
No |
| 06/19/2024 |
3.27.0 |
FFS-51-001-1 |
UPDATE |
Ta min |
0 |
|
| 06/19/2024 |
3.27.0 |
FFS-51-001-1 |
UPDATE |
Ta max |
0.05 |
|
| 06/19/2024 |
3.27.0 |
FFS-51-001-1 |
UPDATE |
Annotation |
Calculate the percentage of S-CHIP FFS: 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 |
FFS-51-001-1 |
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 FFS: 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 = "A"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 |
FFS-50-008-8 |
UPDATE |
Priority |
High |
N/A |
| 06/19/2024 |
3.27.0 |
FFS-50-008-8 |
UPDATE |
Category |
Provider information |
N/A |
| 06/19/2024 |
3.27.0 |
FFS-50-008-8 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 06/19/2024 |
3.27.0 |
FFS-50-008-8 |
UPDATE |
For ta inferential |
Yes |
No |
| 06/19/2024 |
3.27.0 |
FFS-50-008-8 |
UPDATE |
Ta min |
0 |
|
| 06/19/2024 |
3.27.0 |
FFS-50-008-8 |
UPDATE |
Ta max |
0.01 |
|
| 06/19/2024 |
3.27.0 |
FFS-50-008-8 |
UPDATE |
Annotation |
Calculate the percentage Medicaid FFS: original and adjustment, paid RX claims with an invalid billing provider NPI number |
N/A |
| 06/19/2024 |
3.27.0 |
FFS-50-008-8 |
UPDATE |
Specification |
STEP 1: Active non-duplicate paid RX claims during 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 FFS: 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 = "1"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 |
FFS-50-007-7 |
UPDATE |
Priority |
High |
N/A |
| 06/19/2024 |
3.27.0 |
FFS-50-007-7 |
UPDATE |
Category |
Provider information |
N/A |
| 06/19/2024 |
3.27.0 |
FFS-50-007-7 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 06/19/2024 |
3.27.0 |
FFS-50-007-7 |
UPDATE |
For ta inferential |
Yes |
No |
| 06/19/2024 |
3.27.0 |
FFS-50-007-7 |
UPDATE |
Ta min |
0 |
|
| 06/19/2024 |
3.27.0 |
FFS-50-007-7 |
UPDATE |
Ta max |
0.01 |
|
| 06/19/2024 |
3.27.0 |
FFS-50-007-7 |
UPDATE |
Annotation |
Calculate the percentage Medicaid FFS: original and adjustment, paid OT claims with an invalid billing provider NPI number |
N/A |
| 06/19/2024 |
3.27.0 |
FFS-50-007-7 |
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: Medicaid FFS: 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 = "1"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 |
FFS-50-006-6 |
UPDATE |
Priority |
High |
N/A |
| 06/19/2024 |
3.27.0 |
FFS-50-006-6 |
UPDATE |
Category |
Provider information |
N/A |
| 06/19/2024 |
3.27.0 |
FFS-50-006-6 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 06/19/2024 |
3.27.0 |
FFS-50-006-6 |
UPDATE |
For ta inferential |
Yes |
No |
| 06/19/2024 |
3.27.0 |
FFS-50-006-6 |
UPDATE |
Ta min |
0 |
|
| 06/19/2024 |
3.27.0 |
FFS-50-006-6 |
UPDATE |
Ta max |
0.01 |
|
| 06/19/2024 |
3.27.0 |
FFS-50-006-6 |
UPDATE |
Annotation |
Calculate the percentage Medicaid FFS: original and adjustment, paid LT claims with an invalid billing provider NPI number |
N/A |
| 06/19/2024 |
3.27.0 |
FFS-50-006-6 |
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: Medicaid FFS: 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 = "1"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 |
FFS-50-005-5 |
UPDATE |
Priority |
High |
N/A |
| 06/19/2024 |
3.27.0 |
FFS-50-005-5 |
UPDATE |
Category |
Provider information |
N/A |
| 06/19/2024 |
3.27.0 |
FFS-50-005-5 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 06/19/2024 |
3.27.0 |
FFS-50-005-5 |
UPDATE |
For ta inferential |
Yes |
No |
| 06/19/2024 |
3.27.0 |
FFS-50-005-5 |
UPDATE |
Ta min |
0 |
|
| 06/19/2024 |
3.27.0 |
FFS-50-005-5 |
UPDATE |
Ta max |
0.01 |
|
| 06/19/2024 |
3.27.0 |
FFS-50-005-5 |
UPDATE |
Annotation |
Calculate the percentage Medicaid FFS: original and adjustment, paid IP claims with an invalid billing provider NPI number |
N/A |
| 06/19/2024 |
3.27.0 |
FFS-50-005-5 |
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: Medicaid FFS: 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 = "1"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 |
FFS-50-003-3 |
UPDATE |
Priority |
High |
N/A |
| 06/19/2024 |
3.27.0 |
FFS-50-003-3 |
UPDATE |
Category |
Provider information |
N/A |
| 06/19/2024 |
3.27.0 |
FFS-50-003-3 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 06/19/2024 |
3.27.0 |
FFS-50-003-3 |
UPDATE |
For ta inferential |
Yes |
No |
| 06/19/2024 |
3.27.0 |
FFS-50-003-3 |
UPDATE |
Ta min |
0 |
|
| 06/19/2024 |
3.27.0 |
FFS-50-003-3 |
UPDATE |
Ta max |
0.05 |
|
| 06/19/2024 |
3.27.0 |
FFS-50-003-3 |
UPDATE |
Annotation |
Calculate the percentage of Medicaid FFS: 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 |
FFS-50-003-3 |
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: Medicaid FFS: 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 = "1"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 |
FFS-50-002-2 |
UPDATE |
Priority |
High |
N/A |
| 06/19/2024 |
3.27.0 |
FFS-50-002-2 |
UPDATE |
Category |
Provider information |
N/A |
| 06/19/2024 |
3.27.0 |
FFS-50-002-2 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 06/19/2024 |
3.27.0 |
FFS-50-002-2 |
UPDATE |
For ta inferential |
Yes |
No |
| 06/19/2024 |
3.27.0 |
FFS-50-002-2 |
UPDATE |
Ta min |
0 |
|
| 06/19/2024 |
3.27.0 |
FFS-50-002-2 |
UPDATE |
Ta max |
0.05 |
|
| 06/19/2024 |
3.27.0 |
FFS-50-002-2 |
UPDATE |
Annotation |
Calculate the percentage of Medicaid FFS: 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 |
FFS-50-002-2 |
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: Medicaid FFS: 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 = "1"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 |
FFS-50-001-1 |
UPDATE |
Priority |
High |
N/A |
| 06/19/2024 |
3.27.0 |
FFS-50-001-1 |
UPDATE |
Category |
Provider information |
N/A |
| 06/19/2024 |
3.27.0 |
FFS-50-001-1 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 06/19/2024 |
3.27.0 |
FFS-50-001-1 |
UPDATE |
For ta inferential |
Yes |
No |
| 06/19/2024 |
3.27.0 |
FFS-50-001-1 |
UPDATE |
Ta min |
0 |
|
| 06/19/2024 |
3.27.0 |
FFS-50-001-1 |
UPDATE |
Ta max |
0.05 |
|
| 06/19/2024 |
3.27.0 |
FFS-50-001-1 |
UPDATE |
Annotation |
Calculate the percentage of Medicaid FFS: 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 |
FFS-50-001-1 |
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: Medicaid FFS: 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 = "1"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 |
EL-6-027-27 |
UPDATE |
Priority |
High |
N/A |
| 06/19/2024 |
3.27.0 |
EL-6-027-27 |
UPDATE |
Category |
Beneficiary eligibility |
N/A |
| 06/19/2024 |
3.27.0 |
EL-6-027-27 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 06/19/2024 |
3.27.0 |
EL-6-027-27 |
UPDATE |
For ta inferential |
Yes |
No |
| 06/19/2024 |
3.27.0 |
EL-6-027-27 |
UPDATE |
Ta min |
0 |
|
| 06/19/2024 |
3.27.0 |
EL-6-027-27 |
UPDATE |
Ta max |
0.01 |
|
| 06/19/2024 |
3.27.0 |
EL-6-027-27 |
UPDATE |
Annotation |
Calculate the percentage who have a partial dual code in the dual eligible code element but do not have the dual indicator in their restricted benefits code |
N/A |
| 06/19/2024 |
3.27.0 |
EL-6-027-27 |
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: Partial dualsOf the MSIS IDs which meet the criteria from STEP 2, restrict to those with a partial dual indicated in their dual eligible code :1. DUAL-ELIGIBLE-CODE = ("01" or "03" or "05" or "06")STEP 4: Not restricted benefit dualsOf the MSIS IDs that meet the criteria from STEP 3, further refine the population that satisfy the following criteria:1. RESTRICTED-BENEFITS-CODE is not equal to "3" or "G" or 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 |
| 06/19/2024 |
3.27.0 |
EL-6-026-26 |
UPDATE |
Priority |
High |
N/A |
| 06/19/2024 |
3.27.0 |
EL-6-026-26 |
UPDATE |
Category |
Beneficiary eligibility |
N/A |
| 06/19/2024 |
3.27.0 |
EL-6-026-26 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 06/19/2024 |
3.27.0 |
EL-6-026-26 |
UPDATE |
For ta inferential |
Yes |
No |
| 06/19/2024 |
3.27.0 |
EL-6-026-26 |
UPDATE |
Ta min |
0 |
|
| 06/19/2024 |
3.27.0 |
EL-6-026-26 |
UPDATE |
Ta max |
0.01 |
|
| 06/19/2024 |
3.27.0 |
EL-6-026-26 |
UPDATE |
Annotation |
Calculate the percentage of RBC dual eligibles who do not have a partial dual code in the dual eligible code element |
N/A |
| 06/19/2024 |
3.27.0 |
EL-6-026-26 |
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: 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: Restricted benefit dualsOf the MSIS IDs which meet the criteria from STEP 2, restrict to those that are RBC duals:1. RESTRICTED-BENEFITS-CODE = "3" or "G"STEP 4: No partial dual codeOf the MSIS IDs that meet the criteria from STEP 3, further refine the population that satisfy the following criteria:1. DUAL-ELIGIBLE-CODE is not equal to ("01", "03", "05", "06") or 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 |
EL-3-017-22 |
UPDATE |
Focus area |
N/A |
Unwinding |
| 02/02/2024 |
3.18.0 |
ALL-16-008-8 |
UPDATE |
Priority |
Critical |
N/A |
| 02/02/2024 |
3.18.0 |
ALL-16-008-8 |
UPDATE |
Category |
File integrity |
N/A |
| 02/02/2024 |
3.18.0 |
ALL-16-008-8 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 02/02/2024 |
3.18.0 |
ALL-16-008-8 |
UPDATE |
For ta inferential |
Yes |
No |
| 02/02/2024 |
3.18.0 |
ALL-16-008-8 |
UPDATE |
Ta min |
0 |
|
| 02/02/2024 |
3.18.0 |
ALL-16-008-8 |
UPDATE |
Ta max |
0.001 |
|
| 02/02/2024 |
3.18.0 |
ALL-16-007-7 |
UPDATE |
Priority |
Critical |
N/A |
| 02/02/2024 |
3.18.0 |
ALL-16-007-7 |
UPDATE |
Category |
File integrity |
N/A |
| 02/02/2024 |
3.18.0 |
ALL-16-007-7 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 02/02/2024 |
3.18.0 |
ALL-16-007-7 |
UPDATE |
For ta inferential |
Yes |
No |
| 02/02/2024 |
3.18.0 |
ALL-16-007-7 |
UPDATE |
Ta min |
0 |
|
| 02/02/2024 |
3.18.0 |
ALL-16-007-7 |
UPDATE |
Ta max |
0.001 |
|
| 02/02/2024 |
3.18.0 |
ALL-16-006-6 |
UPDATE |
Priority |
Critical |
N/A |
| 02/02/2024 |
3.18.0 |
ALL-16-006-6 |
UPDATE |
Category |
File integrity |
N/A |
| 02/02/2024 |
3.18.0 |
ALL-16-006-6 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 02/02/2024 |
3.18.0 |
ALL-16-006-6 |
UPDATE |
For ta inferential |
Yes |
No |
| 02/02/2024 |
3.18.0 |
ALL-16-006-6 |
UPDATE |
Ta min |
0 |
|
| 02/02/2024 |
3.18.0 |
ALL-16-006-6 |
UPDATE |
Ta max |
0.001 |
|
| 02/02/2024 |
3.18.0 |
ALL-16-005-5 |
UPDATE |
Priority |
Critical |
N/A |
| 02/02/2024 |
3.18.0 |
ALL-16-005-5 |
UPDATE |
Category |
File integrity |
N/A |
| 02/02/2024 |
3.18.0 |
ALL-16-005-5 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 02/02/2024 |
3.18.0 |
ALL-16-005-5 |
UPDATE |
For ta inferential |
Yes |
No |
| 02/02/2024 |
3.18.0 |
ALL-16-005-5 |
UPDATE |
Ta min |
0 |
|
| 02/02/2024 |
3.18.0 |
ALL-16-005-5 |
UPDATE |
Ta max |
0.001 |
|
| 02/02/2024 |
3.18.0 |
ALL-16-004-4 |
UPDATE |
Priority |
Critical |
N/A |
| 02/02/2024 |
3.18.0 |
ALL-16-004-4 |
UPDATE |
Category |
File integrity |
N/A |
| 02/02/2024 |
3.18.0 |
ALL-16-004-4 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 02/02/2024 |
3.18.0 |
ALL-16-004-4 |
UPDATE |
For ta inferential |
Yes |
No |
| 02/02/2024 |
3.18.0 |
ALL-16-004-4 |
UPDATE |
Ta min |
0 |
|
| 02/02/2024 |
3.18.0 |
ALL-16-004-4 |
UPDATE |
Ta max |
0.001 |
|
| 02/02/2024 |
3.18.0 |
ALL-16-003-3 |
UPDATE |
Priority |
Critical |
N/A |
| 02/02/2024 |
3.18.0 |
ALL-16-003-3 |
UPDATE |
Category |
File integrity |
N/A |
| 02/02/2024 |
3.18.0 |
ALL-16-003-3 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 02/02/2024 |
3.18.0 |
ALL-16-003-3 |
UPDATE |
For ta inferential |
Yes |
No |
| 02/02/2024 |
3.18.0 |
ALL-16-003-3 |
UPDATE |
Ta min |
0 |
|
| 02/02/2024 |
3.18.0 |
ALL-16-003-3 |
UPDATE |
Ta max |
0.001 |
|
| 02/02/2024 |
3.18.0 |
ALL-16-002-2 |
UPDATE |
Priority |
Critical |
N/A |
| 02/02/2024 |
3.18.0 |
ALL-16-002-2 |
UPDATE |
Category |
File integrity |
N/A |
| 02/02/2024 |
3.18.0 |
ALL-16-002-2 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 02/02/2024 |
3.18.0 |
ALL-16-002-2 |
UPDATE |
For ta inferential |
Yes |
No |
| 02/02/2024 |
3.18.0 |
ALL-16-002-2 |
UPDATE |
Ta min |
0 |
|
| 02/02/2024 |
3.18.0 |
ALL-16-002-2 |
UPDATE |
Ta max |
0.001 |
|
| 02/02/2024 |
3.18.0 |
ALL-16-001-1 |
UPDATE |
Priority |
Critical |
N/A |
| 02/02/2024 |
3.18.0 |
ALL-16-001-1 |
UPDATE |
Category |
File integrity |
N/A |
| 02/02/2024 |
3.18.0 |
ALL-16-001-1 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 02/02/2024 |
3.18.0 |
ALL-16-001-1 |
UPDATE |
For ta inferential |
Yes |
No |
| 02/02/2024 |
3.18.0 |
ALL-16-001-1 |
UPDATE |
Ta min |
0 |
|
| 02/02/2024 |
3.18.0 |
ALL-16-001-1 |
UPDATE |
Ta max |
0.001 |
|
| 02/02/2024 |
3.18.0 |
ALL-15-001-1 |
UPDATE |
Priority |
High |
N/A |
| 02/02/2024 |
3.18.0 |
ALL-15-001-1 |
UPDATE |
Category |
Utilization |
N/A |
| 02/02/2024 |
3.18.0 |
ALL-15-001-1 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 02/02/2024 |
3.18.0 |
ALL-15-001-1 |
UPDATE |
For ta inferential |
Yes |
No |
| 02/02/2024 |
3.18.0 |
ALL-15-001-1 |
UPDATE |
Ta min |
0 |
|
| 02/02/2024 |
3.18.0 |
ALL-15-001-1 |
UPDATE |
Ta max |
0.001 |
|
| 11/15/2023 |
3.16.0 |
ALL-13-003-5 |
UPDATE |
Specification |
STEP 1: Active non-duplicate IP records during DQ report monthDefine the IP 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: Medicaid FFS and Encounter: 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 "3"2. ADJUSTMENT_IND = "0"STEP 3: Non-missing admission dateOf the claims that meet the criteria from STEP 2, restrict to non-missing ADMISSION-DATESTEP 4: Link claims to enrollment time spanKeep all claims from STEP 3 for which the MSIS ID on the claim is also found on an ENROLLMENT-TIME-SPAN-ELG00021 segmentSTEP 5: Alien during date of serviceLink MSIS-IDs from the claims in STEP 4 to the ELIGIBILITY-DETERMINANTS-ELG00005 file segment and keep segments that satisfy the following criteria:1. PRIMARY-ELIGIBILITY-GROUP-IND = 12. RESTRICTED-BENEFIT-CODE = "2"3. Claims ADMISSION-DATE>= ELIGIBILITY-DETERMINANT-EFF-DATE4. Claims ADMISSION-DATE <= ELIGIBILITY-DETERMINANT-END-DATE OR ELIGIBILITY-DETERMINANT-END-DATE is missingSTEP 6: Unique MSIS-IDs in claimsOf the claims that meet the criteria from STEP 5, limit to unique MSIS-IDsSTEP 7: Non-emergency room and non-pregnancy related servicesOf the claims that meet the criteria from STEP 5, restrict to claims with that do NOT have emergency room revenue codes or pregnancy-related diagnosis codes or procedure codes:NOT (1a. REVENUE-CODE equal to ("450", "451", "452", "453", "454", "455", "456", "457", "458", "459", "0450", "0451", "0452", "0453", "0454", "0455", "0456", "0457", "0458", "0459" ,“0981”,“0720”, “0721”, “0722”, “0723”, “0724”, “0729”)OR2a. DIAGNOSIS-CODE-1 through DIAGNOSIS-CODE-12 is found in the Pregnancy CodeSet tab for ICD-10-CM code typesOR3a. PROCEDURE-CODE-1 through PROCEDURE-CODE-6 is found in the Pregnancy CodeSet tab for ICD-10-PCM code types)STEP 8: Calculate percentageDivide the count of unique MSIS-IDs from STEP 7 by the count of MSIS-IDs from STEP 6 |
STEP 1: Active non-duplicate IP records during DQ report monthDefine the IP records 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-ADJUSTMENT-IND.STEP 2: Medicaid FFS and Encounter: 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 "3"2. ADJUSTMENT_IND = "0"STEP 3: Non-missing admission dateOf the claims that meet the criteria from STEP 2, restrict to non-missing ADMISSION-DATESTEP 4: Link claims to enrollment time spanKeep all claims from STEP 3 for which the MSIS ID on the claim is also found on an ENROLLMENT-TIME-SPAN-ELG00021 segmentSTEP 5: Alien during date of serviceLink MSIS-IDs from the claims in STEP 4 to the ELIGIBILITY-DETERMINANTS-ELG00005 file segment and keep segments that satisfy the following criteria:1. PRIMARY-ELIGIBILITY-GROUP-IND = 12. RESTRICTED-BENEFIT-CODE = "2"3. Claims ADMISSION-DATE>= ELIGIBILITY-DETERMINANT-EFF-DATE4. Claims ADMISSION-DATE <= ELIGIBILITY-DETERMINANT-END-DATE OR ELIGIBILITY-DETERMINANT-END-DATE is missingSTEP 6: Unique MSIS-IDs in claimsOf the claims that meet the criteria from STEP 5, limit to unique MSIS-IDsSTEP 7: Non-emergency room and non-pregnancy related servicesOf the claims that meet the criteria from STEP 5, restrict to claims with that do NOT have emergency room revenue codes or pregnancy-related diagnosis codes or procedure codes:NOT (1a. REVENUE-CODE equal to ("450", "451", "452", "453", "454", "455", "456", "457", "458", "459", "0450", "0451", "0452", "0453", "0454", "0455", "0456", "0457", "0458", "0459" ,“0981”,“0720”, “0721”, “0722”, “0723”, “0724”, “0729”)OR2a. DIAGNOSIS-CODE-1 through DIAGNOSIS-CODE-12 is found in the Pregnancy CodeSet tab for ICD-10-CM code typesOR3a. PROCEDURE-CODE-1 through PROCEDURE-CODE-6 is found in the Pregnancy CodeSet tab for ICD-10-PCM code types)STEP 8: Calculate percentageDivide the count of unique MSIS-IDs from STEP 7 by the count of MSIS-IDs from STEP 6 |
| 11/15/2023 |
3.16.0 |
MIS-30-003-3 |
UPDATE |
Priority |
High |
N/A |
| 11/15/2023 |
3.16.0 |
MIS-30-003-3 |
UPDATE |
Category |
Utilization |
N/A |
| 11/15/2023 |
3.16.0 |
MIS-30-003-3 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 11/15/2023 |
3.16.0 |
MIS-30-003-3 |
UPDATE |
For ta inferential |
Yes |
No |
| 11/15/2023 |
3.16.0 |
MIS-30-003-3 |
UPDATE |
Ta min |
0 |
|
| 11/15/2023 |
3.16.0 |
MIS-30-003-3 |
UPDATE |
Ta max |
0.02 |
|
| 11/15/2023 |
3.16.0 |
MIS-30-003-3 |
UPDATE |
Annotation |
Numeric |
N/A |
| 11/15/2023 |
3.16.0 |
MIS-30-003-3 |
UPDATE |
Specification |
STEP 1: Active non-duplicate OT claims during DQ 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 and S-CHIP Capitation Payment: 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 = "2" or "B"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-30-002-2 |
UPDATE |
Priority |
High |
N/A |
| 02/02/2024 |
3.18.0 |
MIS-30-002-2 |
UPDATE |
Category |
Expenditures |
N/A |
| 02/02/2024 |
3.18.0 |
MIS-30-002-2 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 02/02/2024 |
3.18.0 |
MIS-30-002-2 |
UPDATE |
For ta inferential |
Yes |
No |
| 02/02/2024 |
3.18.0 |
MIS-30-002-2 |
UPDATE |
Ta min |
0 |
|
| 02/02/2024 |
3.18.0 |
MIS-30-002-2 |
UPDATE |
Ta max |
0.02 |
|
| 11/15/2023 |
3.16.0 |
MIS-30-001-1 |
UPDATE |
Priority |
High |
N/A |
| 11/15/2023 |
3.16.0 |
MIS-30-001-1 |
UPDATE |
Category |
Utilization |
N/A |
| 11/15/2023 |
3.16.0 |
MIS-30-001-1 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 11/15/2023 |
3.16.0 |
MIS-30-001-1 |
UPDATE |
For ta inferential |
Yes |
No |
| 11/15/2023 |
3.16.0 |
MIS-30-001-1 |
UPDATE |
Ta min |
0 |
|
| 11/15/2023 |
3.16.0 |
MIS-30-001-1 |
UPDATE |
Ta max |
0.02 |
|
| 11/15/2023 |
3.16.0 |
MIS-30-001-1 |
UPDATE |
Annotation |
Numeric |
N/A |
| 11/15/2023 |
3.16.0 |
MIS-30-001-1 |
UPDATE |
Specification |
STEP 1: Active non-duplicate OT claims during DQ 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 and S-CHIP Capitation Payment: 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 = "2" or "B"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-29-002-2 |
UPDATE |
Priority |
Critical |
N/A |
| 11/15/2023 |
3.16.0 |
MIS-29-002-2 |
UPDATE |
Category |
File integrity |
N/A |
| 11/15/2023 |
3.16.0 |
MIS-29-002-2 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 11/15/2023 |
3.16.0 |
MIS-29-002-2 |
UPDATE |
For ta inferential |
Yes |
No |
| 11/15/2023 |
3.16.0 |
MIS-29-002-2 |
UPDATE |
Ta min |
0 |
|
| 11/15/2023 |
3.16.0 |
MIS-29-002-2 |
UPDATE |
Ta max |
0.02 |
|
| 11/15/2023 |
3.16.0 |
MIS-29-002-2 |
UPDATE |
Annotation |
Numeric |
N/A |
| 11/15/2023 |
3.16.0 |
MIS-29-002-2 |
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 Capitation Payment: 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 = "2" or "B"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-29-001-1 |
UPDATE |
Priority |
Critical |
N/A |
| 11/15/2023 |
3.16.0 |
MIS-29-001-1 |
UPDATE |
Category |
File integrity |
N/A |
| 11/15/2023 |
3.16.0 |
MIS-29-001-1 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 11/15/2023 |
3.16.0 |
MIS-29-001-1 |
UPDATE |
For ta inferential |
Yes |
No |
| 11/15/2023 |
3.16.0 |
MIS-29-001-1 |
UPDATE |
Ta min |
0 |
|
| 11/15/2023 |
3.16.0 |
MIS-29-001-1 |
UPDATE |
Ta max |
0.02 |
|
| 11/15/2023 |
3.16.0 |
MIS-29-001-1 |
UPDATE |
Annotation |
Numeric |
N/A |
| 11/15/2023 |
3.16.0 |
MIS-29-001-1 |
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 Capitation Payment: 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 = "2" or "B"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-28-001-1 |
UPDATE |
Priority |
High |
N/A |
| 02/02/2024 |
3.18.0 |
MIS-28-001-1 |
UPDATE |
Category |
Expenditures |
N/A |
| 02/02/2024 |
3.18.0 |
MIS-28-001-1 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 02/02/2024 |
3.18.0 |
MIS-28-001-1 |
UPDATE |
For ta inferential |
Yes |
No |
| 02/02/2024 |
3.18.0 |
MIS-28-001-1 |
UPDATE |
Ta min |
0 |
|
| 02/02/2024 |
3.18.0 |
MIS-28-001-1 |
UPDATE |
Ta max |
0.1 |
|
| 02/02/2024 |
3.18.0 |
MIS-26-001-1 |
UPDATE |
Priority |
High |
N/A |
| 02/02/2024 |
3.18.0 |
MIS-26-001-1 |
UPDATE |
Category |
Expenditures |
N/A |
| 02/02/2024 |
3.18.0 |
MIS-26-001-1 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 02/02/2024 |
3.18.0 |
MIS-26-001-1 |
UPDATE |
For ta inferential |
Yes |
No |
| 02/02/2024 |
3.18.0 |
MIS-26-001-1 |
UPDATE |
Ta min |
0 |
|
| 02/02/2024 |
3.18.0 |
MIS-26-001-1 |
UPDATE |
Ta max |
0.1 |
|
| 02/02/2024 |
3.18.0 |
MIS-24-001-1 |
UPDATE |
Priority |
High |
N/A |
| 02/02/2024 |
3.18.0 |
MIS-24-001-1 |
UPDATE |
Category |
Expenditures |
N/A |
| 02/02/2024 |
3.18.0 |
MIS-24-001-1 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 02/02/2024 |
3.18.0 |
MIS-24-001-1 |
UPDATE |
For ta inferential |
Yes |
No |
| 02/02/2024 |
3.18.0 |
MIS-24-001-1 |
UPDATE |
Ta min |
0 |
|
| 02/02/2024 |
3.18.0 |
MIS-24-001-1 |
UPDATE |
Ta max |
0.1 |
|
| 02/02/2024 |
3.18.0 |
MIS-22-001-1 |
UPDATE |
Priority |
High |
N/A |
| 02/02/2024 |
3.18.0 |
MIS-22-001-1 |
UPDATE |
Category |
Expenditures |
N/A |
| 02/02/2024 |
3.18.0 |
MIS-22-001-1 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 02/02/2024 |
3.18.0 |
MIS-22-001-1 |
UPDATE |
For ta inferential |
Yes |
No |
| 02/02/2024 |
3.18.0 |
MIS-22-001-1 |
UPDATE |
Ta min |
0 |
|
| 02/02/2024 |
3.18.0 |
MIS-22-001-1 |
UPDATE |
Ta max |
0.1 |
|
| 02/02/2024 |
3.18.0 |
MIS-19-001-1 |
UPDATE |
Priority |
Critical |
N/A |
| 02/02/2024 |
3.18.0 |
MIS-19-001-1 |
UPDATE |
Category |
File integrity |
N/A |
| 02/02/2024 |
3.18.0 |
MIS-19-001-1 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 02/02/2024 |
3.18.0 |
MIS-19-001-1 |
UPDATE |
For ta inferential |
Yes |
No |
| 02/02/2024 |
3.18.0 |
MIS-19-001-1 |
UPDATE |
Ta min |
0 |
|
| 02/02/2024 |
3.18.0 |
MIS-19-001-1 |
UPDATE |
Ta max |
0.02 |
|
| 02/02/2024 |
3.18.0 |
MIS-17-001-1 |
UPDATE |
Priority |
Critical |
N/A |
| 02/02/2024 |
3.18.0 |
MIS-17-001-1 |
UPDATE |
Category |
File integrity |
N/A |
| 02/02/2024 |
3.18.0 |
MIS-17-001-1 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 02/02/2024 |
3.18.0 |
MIS-17-001-1 |
UPDATE |
For ta inferential |
Yes |
No |
| 02/02/2024 |
3.18.0 |
MIS-17-001-1 |
UPDATE |
Ta min |
0 |
|
| 02/02/2024 |
3.18.0 |
MIS-17-001-1 |
UPDATE |
Ta max |
0.02 |
|
| 02/02/2024 |
3.18.0 |
MIS-15-001-1 |
UPDATE |
Priority |
Critical |
N/A |
| 02/02/2024 |
3.18.0 |
MIS-15-001-1 |
UPDATE |
Category |
File integrity |
N/A |
| 02/02/2024 |
3.18.0 |
MIS-15-001-1 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 02/02/2024 |
3.18.0 |
MIS-15-001-1 |
UPDATE |
For ta inferential |
Yes |
No |
| 02/02/2024 |
3.18.0 |
MIS-15-001-1 |
UPDATE |
Ta min |
0 |
|
| 02/02/2024 |
3.18.0 |
MIS-15-001-1 |
UPDATE |
Ta max |
0.02 |
|
| 02/02/2024 |
3.18.0 |
MIS-13-001-1 |
UPDATE |
Priority |
Critical |
N/A |
| 02/02/2024 |
3.18.0 |
MIS-13-001-1 |
UPDATE |
Category |
File integrity |
N/A |
| 02/02/2024 |
3.18.0 |
MIS-13-001-1 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 02/02/2024 |
3.18.0 |
MIS-13-001-1 |
UPDATE |
For ta inferential |
Yes |
No |
| 02/02/2024 |
3.18.0 |
MIS-13-001-1 |
UPDATE |
Ta min |
0 |
|
| 02/02/2024 |
3.18.0 |
MIS-13-001-1 |
UPDATE |
Ta max |
0.02 |
|
| 11/15/2023 |
3.16.0 |
FFS-48-001-1 |
UPDATE |
Priority |
Critical |
N/A |
| 11/15/2023 |
3.16.0 |
FFS-48-001-1 |
UPDATE |
Category |
File integrity |
N/A |
| 11/15/2023 |
3.16.0 |
FFS-48-001-1 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 11/15/2023 |
3.16.0 |
FFS-48-001-1 |
UPDATE |
For ta inferential |
Yes |
No |
| 11/15/2023 |
3.16.0 |
FFS-48-001-1 |
UPDATE |
Ta min |
0 |
|
| 11/15/2023 |
3.16.0 |
FFS-48-001-1 |
UPDATE |
Ta max |
0.05 |
|
| 11/15/2023 |
3.16.0 |
FFS-48-001-1 |
UPDATE |
Annotation |
The percentage of claims that are S-CHIP FFS: original and adjustment, and paid where patient status is not "Still a patient" and the discharge date is missing |
N/A |
| 11/15/2023 |
3.16.0 |
FFS-48-001-1 |
UPDATE |
Specification |
STEP 1: Active non-duplicate IP records during DQ report monthDefine the IP 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 FFS: 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 = "A"STEP 3: Patient status is not "Still a Patient"Of the claims that meet the criteria from STEP 2, further restrict them by the following criteria: 1. PATIENT-STATUS is not equal to "30"2. PATIENT-STATUS is not missingSTEP 4: Missing discharge dateOf the claims from STEP 3, select records where:1. DISCHARGE-DATE is missingSTEP 5: Calculate percentageDivide the number of claims from STEP 4 by the number of claims from STEP 3 |
N/A |
| 11/15/2023 |
3.16.0 |
FFS-47-001-1 |
UPDATE |
Priority |
Critical |
N/A |
| 11/15/2023 |
3.16.0 |
FFS-47-001-1 |
UPDATE |
Category |
File integrity |
N/A |
| 11/15/2023 |
3.16.0 |
FFS-47-001-1 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 11/15/2023 |
3.16.0 |
FFS-47-001-1 |
UPDATE |
For ta inferential |
Yes |
No |
| 11/15/2023 |
3.16.0 |
FFS-47-001-1 |
UPDATE |
Ta min |
0 |
|
| 11/15/2023 |
3.16.0 |
FFS-47-001-1 |
UPDATE |
Ta max |
0.05 |
|
| 11/15/2023 |
3.16.0 |
FFS-47-001-1 |
UPDATE |
Annotation |
The percentage of claims that are Medicaid FFS: original and adjustment, and paid where patient status is not "Still a patient" and the discharge date is missing |
N/A |
| 11/15/2023 |
3.16.0 |
FFS-47-001-1 |
UPDATE |
Specification |
STEP 1: Active non-duplicate IP records during DQ report monthDefine the IP 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: Medicaid FFS: 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 = "1"STEP 3: Patient status is not "Still a Patient"Of the claims that meet the criteria from STEP 2, further restrict them by the following criteria: 1. PATIENT-STATUS is not equal to "30"2. PATIENT-STATUS is not missingSTEP 4: Missing discharge dateOf the claims from STEP 3, select records where:1. DISCHARGE-DATE is missingSTEP 5: Calculate percentageDivide the number of claims from STEP 4 by the number of claims from STEP 3 |
N/A |
| 02/02/2024 |
3.18.0 |
EXP-39-001-1 |
UPDATE |
Focus area |
Managed care |
N/A |
| 02/02/2024 |
3.18.0 |
EXP-37-001-1 |
UPDATE |
Focus area |
Managed care |
N/A |
| 03/27/2024 |
3.22.0 |
EL-6-023-23 |
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: Full-benefit enrolleesOf the MSIS ID's that meet the criteria from step 2, count the unique number of MSIS IDs where:1. RESTRICTED-BENEFITS-CODE = ("1", "7", "A", "B", "D") or is missing**Note: This can include MSIS IDs from STEP 1 that did not join to an eligibility determinants segment. |
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: Full-benefit enrolleesOf the MSIS ID's that meet the criteria from step 2, count the unique number of MSIS IDs where:1. RESTRICTED-BENEFITS-CODE = ("1", "4", "5" "7", "A", "B", "D") or is missing**Note: This can include MSIS IDs from STEP 1 that did not join to an eligibility determinants segment. |
| 02/02/2024 |
3.18.0 |
EL-15-002-2 |
UPDATE |
Focus area |
N/A |
Unwinding |
| 02/02/2024 |
3.18.0 |
EL-15-001-1 |
UPDATE |
Focus area |
N/A |
Unwinding |
| 11/15/2023 |
3.16.0 |
MIS-9-019-19 |
UPDATE |
Measure name |
% missing: OT-RX-CLAIM-QUANTITY-ACTUAL (CRX00003) |
% missing: PRESCRIPTION-QUANTITY-ACTUAL (CRX00003) |
| 11/15/2023 |
3.16.0 |
MIS-9-007-7 |
UPDATE |
Measure name |
% missing: DISPENSE-FEE (CRX00003) |
% missing: DISPENSE-FEE-SUBMITTED (CRX00003) |
| 11/15/2023 |
3.16.0 |
MIS-9-005-5 |
UPDATE |
Measure name |
% missing: COPAY-AMT (CRX00003) |
% missing: BENEFICIARY-COPAYMENT-PAID-AMOUNT (CRX00003) |
| 11/15/2023 |
3.16.0 |
MIS-8-005-5 |
UPDATE |
Measure name |
% missing: BENEFICIARY-DEDUCTIBLE-AMOUNT (CRX00002) |
% missing: TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT (CRX00002) |
| 11/15/2023 |
3.16.0 |
MIS-8-004-4 |
UPDATE |
Measure name |
% missing: BENEFICIARY-COPAYMENT-AMOUNT (CRX00002) |
% missing: TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT (CRX00002) |
| 11/15/2023 |
3.16.0 |
MIS-8-003-3 |
UPDATE |
Measure name |
% missing: BENEFICIARY-COINSURANCE-AMOUNT (CRX00002) |
% missing: TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT (CRX00002) |
| 11/15/2023 |
3.16.0 |
MIS-7-020-20 |
UPDATE |
Measure name |
% missing: OT-RX-CLAIM-QUANTITY-ACTUAL (COT00003) |
% missing: SERVICE-QUANTITY-ACTUAL (COT00003) |
| 11/15/2023 |
3.16.0 |
MIS-7-005-5 |
UPDATE |
Measure name |
% missing: COPAY-AMT (COT00003) |
% missing: BENEFICIARY-COPAYMENT-PAID-AMOUNT (COT00003) |
| 11/15/2023 |
3.16.0 |
MIS-6-006-6 |
UPDATE |
Measure name |
% missing: BENEFICIARY-DEDUCTIBLE-AMOUNT (COT00002) |
% missing: TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT (COT00002) |
| 11/15/2023 |
3.16.0 |
MIS-6-005-5 |
UPDATE |
Measure name |
% missing: BENEFICIARY-COPAYMENT-AMOUNT (COT00002) |
% missing: TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT (COT00002) |
| 11/15/2023 |
3.16.0 |
MIS-6-004-4 |
UPDATE |
Measure name |
% missing: BENEFICIARY-COINSURANCE-AMOUNT (COT00002) |
% missing: TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT (COT00002) |
| 11/15/2023 |
3.16.0 |
MIS-4-006-6 |
UPDATE |
Measure name |
% missing: BENEFICIARY-DEDUCTIBLE-AMOUNT (CLT00002) |
% missing: TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT (CLT00002) |
| 11/15/2023 |
3.16.0 |
MIS-4-005-5 |
UPDATE |
Measure name |
% missing: BENEFICIARY-COPAYMENT-AMOUNT (CLT00002) |
% missing: TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT (CLT00002) |
| 11/15/2023 |
3.16.0 |
MIS-4-004-4 |
UPDATE |
Measure name |
% missing: BENEFICIARY-COINSURANCE-AMOUNT (CLT00002) |
% missing: TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT (CLT00002) |
| 11/15/2023 |
3.16.0 |
MIS-2-007-7 |
UPDATE |
Measure name |
% missing: BENEFICIARY-DEDUCTIBLE-AMOUNT (CIP00002) |
% missing: TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT (CIP00002) |
| 11/15/2023 |
3.16.0 |
MIS-2-006-6 |
UPDATE |
Measure name |
% missing: BENEFICIARY-COPAYMENT-AMOUNT (CIP00002) |
% missing: TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT (CIP00002) |
| 11/15/2023 |
3.16.0 |
MIS-2-005-5 |
UPDATE |
Measure name |
% missing: BENEFICIARY-COINSURANCE-AMOUNT (CIP00002) |
% missing: TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT (CIP00002) |
| 03/27/2024 |
3.22.0 |
MIS-11-039-39 |
UPDATE |
Priority |
High |
N/A |
| 03/27/2024 |
3.22.0 |
MIS-11-039-39 |
UPDATE |
Category |
Provider characteristics |
N/A |
| 03/27/2024 |
3.22.0 |
MIS-11-039-39 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 03/27/2024 |
3.22.0 |
MIS-11-039-39 |
UPDATE |
For ta inferential |
Yes |
No |
| 03/27/2024 |
3.22.0 |
MIS-11-039-39 |
UPDATE |
Ta min |
0 |
|
| 03/27/2024 |
3.22.0 |
MIS-11-039-39 |
UPDATE |
Ta max |
0.02 |
|
| 03/27/2024 |
3.22.0 |
MIS-11-039-39 |
UPDATE |
Annotation |
Alphanumeric |
N/A |
| 03/27/2024 |
3.22.0 |
MIS-11-039-39 |
UPDATE |
Specification |
STEP 1: Any active record segmentKeep all active records from segment (PRV000XX)STEP 2: Alphanumeric missing flagCreate a binary flag called Alphanumeric_Missing that is equal to 1 when1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9STEP 3: All alphanumeric missingOf the SUBMITTING-STATE-PROV-IDs identified in STEP 1, select those where Alphanumeric_Missing = 1 for all record segments for each particular SUBMITTING-STATE-PROV-IDSTEP 4: Calculate percentageDivide the count of unique SUBMITTING-STATE-PROV-IDs from STEP 3 by the count of unique SUBMITTING-STATE-PROV-IDs from STEP 1 |
N/A |
| 03/27/2024 |
3.22.0 |
MIS-11-038-38 |
UPDATE |
Priority |
High |
N/A |
| 03/27/2024 |
3.22.0 |
MIS-11-038-38 |
UPDATE |
Category |
Provider characteristics |
N/A |
| 03/27/2024 |
3.22.0 |
MIS-11-038-38 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 03/27/2024 |
3.22.0 |
MIS-11-038-38 |
UPDATE |
For ta inferential |
Yes |
No |
| 03/27/2024 |
3.22.0 |
MIS-11-038-38 |
UPDATE |
Ta min |
0 |
|
| 03/27/2024 |
3.22.0 |
MIS-11-038-38 |
UPDATE |
Ta max |
0.02 |
|
| 03/27/2024 |
3.22.0 |
MIS-11-038-38 |
UPDATE |
Annotation |
Alphanumeric |
N/A |
| 03/27/2024 |
3.22.0 |
MIS-11-038-38 |
UPDATE |
Specification |
STEP 1: Any active record segmentKeep all active records from segment (PRV000XX)STEP 2: Alphanumeric missing flagCreate a binary flag called Alphanumeric_Missing that is equal to 1 when1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9STEP 3: All alphanumeric missingOf the SUBMITTING-STATE-PROV-IDs identified in STEP 1, select those where Alphanumeric_Missing = 1 for all record segments for each particular SUBMITTING-STATE-PROV-IDSTEP 4: Calculate percentageDivide the count of unique SUBMITTING-STATE-PROV-IDs from STEP 3 by the count of unique SUBMITTING-STATE-PROV-IDs from STEP 1 |
N/A |
| 03/27/2024 |
3.22.0 |
MIS-11-035-35 |
UPDATE |
Priority |
High |
N/A |
| 03/27/2024 |
3.22.0 |
MIS-11-035-35 |
UPDATE |
Category |
Provider identifiers |
N/A |
| 03/27/2024 |
3.22.0 |
MIS-11-035-35 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 03/27/2024 |
3.22.0 |
MIS-11-035-35 |
UPDATE |
For ta inferential |
Yes |
No |
| 03/27/2024 |
3.22.0 |
MIS-11-035-35 |
UPDATE |
Ta min |
0 |
|
| 03/27/2024 |
3.22.0 |
MIS-11-035-35 |
UPDATE |
Ta max |
0.02 |
|
| 03/27/2024 |
3.22.0 |
MIS-11-035-35 |
UPDATE |
Annotation |
Alphanumeric |
N/A |
| 03/27/2024 |
3.22.0 |
MIS-11-035-35 |
UPDATE |
Specification |
STEP 1: Any active record segmentKeep all active records from segment (PRV000XX)STEP 2: Alphanumeric missing flagCreate a binary flag called Alphanumeric_Missing that is equal to 1 when1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9STEP 3: All alphanumeric missingOf the SUBMITTING-STATE-PROV-IDs identified in STEP 1, select those where Alphanumeric_Missing = 1 for all record segments for each particular SUBMITTING-STATE-PROV-IDSTEP 4: Calculate percentageDivide the count of unique SUBMITTING-STATE-PROV-IDs from STEP 3 by the count of unique SUBMITTING-STATE-PROV-IDs from STEP 1 |
N/A |
| 03/27/2024 |
3.22.0 |
MIS-11-034-34 |
UPDATE |
Priority |
High |
N/A |
| 03/27/2024 |
3.22.0 |
MIS-11-034-34 |
UPDATE |
Category |
Provider identifiers |
N/A |
| 03/27/2024 |
3.22.0 |
MIS-11-034-34 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 03/27/2024 |
3.22.0 |
MIS-11-034-34 |
UPDATE |
For ta inferential |
Yes |
No |
| 03/27/2024 |
3.22.0 |
MIS-11-034-34 |
UPDATE |
Ta min |
0 |
|
| 03/27/2024 |
3.22.0 |
MIS-11-034-34 |
UPDATE |
Ta max |
0.02 |
|
| 03/27/2024 |
3.22.0 |
MIS-11-034-34 |
UPDATE |
Annotation |
Alphanumeric |
N/A |
| 03/27/2024 |
3.22.0 |
MIS-11-034-34 |
UPDATE |
Specification |
STEP 1: Any active record segmentKeep all active records from segment (PRV000XX)STEP 2: Alphanumeric missing flagCreate a binary flag called Alphanumeric_Missing that is equal to 1 when1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9STEP 3: All alphanumeric missingOf the SUBMITTING-STATE-PROV-IDs identified in STEP 1, select those where Alphanumeric_Missing = 1 for all record segments for each particular SUBMITTING-STATE-PROV-IDSTEP 4: Calculate percentageDivide the count of unique SUBMITTING-STATE-PROV-IDs from STEP 3 by the count of unique SUBMITTING-STATE-PROV-IDs from STEP 1 |
N/A |
| 03/27/2024 |
3.22.0 |
MIS-11-032-32 |
UPDATE |
Priority |
High |
N/A |
| 03/27/2024 |
3.22.0 |
MIS-11-032-32 |
UPDATE |
Category |
Provider identifiers |
N/A |
| 03/27/2024 |
3.22.0 |
MIS-11-032-32 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 03/27/2024 |
3.22.0 |
MIS-11-032-32 |
UPDATE |
For ta inferential |
Yes |
No |
| 03/27/2024 |
3.22.0 |
MIS-11-032-32 |
UPDATE |
Ta min |
0 |
|
| 03/27/2024 |
3.22.0 |
MIS-11-032-32 |
UPDATE |
Ta max |
0.02 |
|
| 03/27/2024 |
3.22.0 |
MIS-11-032-32 |
UPDATE |
Annotation |
Numeric |
N/A |
| 03/27/2024 |
3.22.0 |
MIS-11-032-32 |
UPDATE |
Specification |
STEP 1: Any active record segmentKeep all active records from segment (PRV000XX) STEP 2: Numeric missing flagCreate a binary flag called Numeric_Missing that is equal to 1 when1. [DATA-ELEMENT-NAME] does not contain any digit 1-9STEP 3: All numeric missingOf the SUBMITTING-STATE-PROV-IDs identified in STEP 1, select those where Numeric_Missing = 1 for all record segments for each particular SUBMITTING-STATE-PROV-IDSTEP 4: Calculate percentageDivide the count of unique SUBMITTING-STATE-PROV-IDs from STEP 3 by the count of unique SUBMITTING-STATE-PROV-IDs from STEP 1 |
N/A |
| 03/27/2024 |
3.22.0 |
MIS-11-031-31 |
UPDATE |
Priority |
High |
N/A |
| 03/27/2024 |
3.22.0 |
MIS-11-031-31 |
UPDATE |
Category |
Provider identifiers |
N/A |
| 03/27/2024 |
3.22.0 |
MIS-11-031-31 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 03/27/2024 |
3.22.0 |
MIS-11-031-31 |
UPDATE |
For ta inferential |
Yes |
No |
| 03/27/2024 |
3.22.0 |
MIS-11-031-31 |
UPDATE |
Ta min |
0 |
|
| 03/27/2024 |
3.22.0 |
MIS-11-031-31 |
UPDATE |
Ta max |
0.02 |
|
| 03/27/2024 |
3.22.0 |
MIS-11-031-31 |
UPDATE |
Annotation |
Alphanumeric |
N/A |
| 03/27/2024 |
3.22.0 |
MIS-11-031-31 |
UPDATE |
Specification |
STEP 1: Any active record segmentKeep all active records from segment (PRV000XX)STEP 2: Alphanumeric missing flagCreate a binary flag called Alphanumeric_Missing that is equal to 1 when1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9STEP 3: All alphanumeric missingOf the SUBMITTING-STATE-PROV-IDs identified in STEP 1, select those where Alphanumeric_Missing = 1 for all record segments for each particular SUBMITTING-STATE-PROV-IDSTEP 4: Calculate percentageDivide the count of unique SUBMITTING-STATE-PROV-IDs from STEP 3 by the count of unique SUBMITTING-STATE-PROV-IDs from STEP 1 |
N/A |
| 11/15/2023 |
3.16.0 |
MIS-11-010-10 |
UPDATE |
Priority |
Medium |
N/A |
| 11/15/2023 |
3.16.0 |
MIS-11-010-10 |
UPDATE |
Category |
Provider identifiers |
N/A |
| 11/15/2023 |
3.16.0 |
MIS-11-010-10 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 11/15/2023 |
3.16.0 |
MIS-11-010-10 |
UPDATE |
For ta inferential |
Yes |
No |
| 11/15/2023 |
3.16.0 |
MIS-11-010-10 |
UPDATE |
Ta min |
0 |
|
| 11/15/2023 |
3.16.0 |
MIS-11-010-10 |
UPDATE |
Ta max |
0.02 |
|
| 11/15/2023 |
3.16.0 |
MIS-11-010-10 |
UPDATE |
Threshold minimum |
0 |
N/A |
| 11/15/2023 |
3.16.0 |
MIS-11-010-10 |
UPDATE |
Threshold maximum |
0.02 |
N/A |
| 03/27/2024 |
3.22.0 |
MIS-11-003-3 |
UPDATE |
Priority |
High |
N/A |
| 03/27/2024 |
3.22.0 |
MIS-11-003-3 |
UPDATE |
Category |
Provider characteristics |
N/A |
| 03/27/2024 |
3.22.0 |
MIS-11-003-3 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 03/27/2024 |
3.22.0 |
MIS-11-003-3 |
UPDATE |
For ta inferential |
Yes |
No |
| 03/27/2024 |
3.22.0 |
MIS-11-003-3 |
UPDATE |
Ta min |
0 |
|
| 03/27/2024 |
3.22.0 |
MIS-11-003-3 |
UPDATE |
Ta max |
0.02 |
|
| 03/27/2024 |
3.22.0 |
MIS-11-003-3 |
UPDATE |
Annotation |
Alphanumeric |
N/A |
| 03/27/2024 |
3.22.0 |
MIS-11-003-3 |
UPDATE |
Specification |
STEP 1: Any active record segmentKeep all active records from segment (PRV000XX)STEP 2: Alphanumeric missing flagCreate a binary flag called Alphanumeric_Missing that is equal to 1 when1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9STEP 3: All alphanumeric missingOf the SUBMITTING-STATE-PROV-IDs identified in STEP 1, select those where Alphanumeric_Missing = 1 for all record segments for each particular SUBMITTING-STATE-PROV-IDSTEP 4: Calculate percentageDivide the count of unique SUBMITTING-STATE-PROV-IDs from STEP 3 by the count of unique SUBMITTING-STATE-PROV-IDs from STEP 1 |
N/A |
| 11/15/2023 |
3.16.0 |
MIS-1-073-73 |
UPDATE |
Specification |
STEP 1: Any active record segmentKeep all active records from segment (ELG000XX)STEP 2: Alphanumeric missing flagCreate a binary flag called Alphanumeric_Missing that is equal to 1 when1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9STEP 3: All alphanumeric missingOf the MSIS-IDs identified in STEP 1, select those where Alphanumeric_Missing = 1 for all record segments for each particular MSIS-IDSTEP 4: Calculate percentageDivide the count of unique MSIS-IDs from STEP 3 by the count of unique MSIS-IDs from STEP 1NOTE:The following value(s) should also be treated as missing for ETHNICITY-CODE (ELG000015):6 |
STEP 1: Any active record segmentKeep all active records from segment (ELG000XX)STEP 2: Alphanumeric missing flagCreate a binary flag called Alphanumeric_Missing that is equal to 1 when1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9STEP 3: All alphanumeric missingOf the MSIS-IDs identified in STEP 1, select those where Alphanumeric_Missing = 1 for all record segments for each particular MSIS-IDSTEP 4: Calculate percentageDivide the count of unique MSIS-IDs from STEP 3 by the count of unique MSIS-IDs from STEP 1NOTE:The following value(s) should also be treated as missing for ETHNICITY-CODE (ELG000015):6The following value(s) should not be treated as missing for ETHNICITY-CODE (ELG000015):0 |
| 03/27/2024 |
3.22.0 |
MIS-1-010-10 |
UPDATE |
Priority |
High |
N/A |
| 03/27/2024 |
3.22.0 |
MIS-1-010-10 |
UPDATE |
Category |
Beneficiary demographics |
N/A |
| 03/27/2024 |
3.22.0 |
MIS-1-010-10 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 03/27/2024 |
3.22.0 |
MIS-1-010-10 |
UPDATE |
For ta inferential |
Yes |
No |
| 03/27/2024 |
3.22.0 |
MIS-1-010-10 |
UPDATE |
Ta min |
0 |
|
| 03/27/2024 |
3.22.0 |
MIS-1-010-10 |
UPDATE |
Ta max |
0.02 |
|
| 03/27/2024 |
3.22.0 |
MIS-1-010-10 |
UPDATE |
Annotation |
Alphanumeric |
N/A |
| 03/27/2024 |
3.22.0 |
MIS-1-010-10 |
UPDATE |
Specification |
STEP 1: Any active record segmentKeep all active records from segment (ELG000XX)STEP 2: Alphanumeric missing flagCreate a binary flag called Alphanumeric_Missing that is equal to 1 when1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9STEP 3: All alphanumeric missingOf the MSIS-IDs identified in STEP 1, select those where Alphanumeric_Missing = 1 for all record segments for each particular MSIS-IDSTEP 4: Calculate percentageDivide the count of unique MSIS-IDs from STEP 3 by the count of unique MSIS-IDs from STEP 1 |
N/A |
| 03/27/2024 |
3.22.0 |
MIS-1-008-8 |
UPDATE |
Priority |
High |
N/A |
| 03/27/2024 |
3.22.0 |
MIS-1-008-8 |
UPDATE |
Category |
Beneficiary demographics |
N/A |
| 03/27/2024 |
3.22.0 |
MIS-1-008-8 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 03/27/2024 |
3.22.0 |
MIS-1-008-8 |
UPDATE |
For ta inferential |
Yes |
No |
| 03/27/2024 |
3.22.0 |
MIS-1-008-8 |
UPDATE |
Ta min |
0 |
|
| 03/27/2024 |
3.22.0 |
MIS-1-008-8 |
UPDATE |
Ta max |
0.2 |
|
| 03/27/2024 |
3.22.0 |
MIS-1-008-8 |
UPDATE |
Annotation |
Alphanumeric |
N/A |
| 03/27/2024 |
3.22.0 |
MIS-1-008-8 |
UPDATE |
Specification |
STEP 1: Any active record segmentKeep all active records from segment (ELG000XX)STEP 2: Alphanumeric missing flagCreate a binary flag called Alphanumeric_Missing that is equal to 1 when1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9STEP 3: All alphanumeric missingOf the MSIS-IDs identified in STEP 1, select those where Alphanumeric_Missing = 1 for all record segments for each particular MSIS-IDSTEP 4: Calculate percentageDivide the count of unique MSIS-IDs from STEP 3 by the count of unique MSIS-IDs from STEP 1 |
N/A |
| 02/02/2024 |
3.18.0 |
MCR-54-009-9 |
UPDATE |
Focus area |
Managed care |
N/A |
| 11/15/2023 |
3.16.0 |
PRV-2-002-2 |
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 missing STEP 2: Provider identifier 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 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 3: Provider classification type is "NPI"Of the providers that meet the criteria from STEP 2, keep records that satisfy the following criteria: 1. PROV-IDENTIFIER-TYPE = 2STEP 4: Calculate percent that that have NPIDivide the count of unique SUBMITTING-STATE-PROV-IDs from STEP 3 by the count from STEP 2 |
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 missing STEP 2: Provider identifier 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 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 3: Provider classification type is "NPI"Of the providers that meet the criteria from STEP 2, keep records that satisfy the following criteria: 1. PROV-IDENTIFIER-TYPE = 2STEP 4: Calculate percent that have NPIDivide the count of unique SUBMITTING-STATE-PROV-IDs from STEP 3 by the count from STEP 2 |
| 11/15/2023 |
3.16.0 |
MCR-19-008-2 |
UPDATE |
Measure name |
% of claim headers with missing OT RX Claim Quantity Actual |
% of claim headers with missing Prescription Quantity Actual |
| 11/15/2023 |
3.16.0 |
MCR-19-008-2 |
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: S-CHIP Encounter: 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 = "C"2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "0" or is missingSTEP 3: Missing OT RX Claim QuantityOf the claims that meet the criteria from STEP 2, further restrict them by the following criteria:1. OT-RX-CLAIM-QUANTITY-ACTUAL is missingSTEP 4: Calculate the percentage for the measureDivide the count of claims from STEP 3 by the count of claims from STEP 2 |
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: S-CHIP Encounter: 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 = "C"2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "0" or is missingSTEP 3: Missing Prescription Quantity ActualOf the claims that meet the criteria from STEP 2, further restrict them by the following criteria:1. PRESCRIPTION-QUANTITY-ACTUAL is missingSTEP 4: Calculate the percentage for the measureDivide the count of claims from STEP 3 by the count of claims from STEP 2 |
| 11/15/2023 |
3.16.0 |
MCR-19-006-4 |
UPDATE |
Measure name |
% of claim headers with OT-RX-CLAIM-QUANTITY-ACTUAL = 1 |
% of claim headers with PRESCRIPTION-QUANTITY-ACTUAL = 1 |
| 02/02/2024 |
3.18.0 |
MCR-19-005-1 |
UPDATE |
Priority |
High |
N/A |
| 02/02/2024 |
3.18.0 |
MCR-19-005-1 |
UPDATE |
Category |
Utilization |
N/A |
| 02/02/2024 |
3.18.0 |
MCR-19-005-1 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 02/02/2024 |
3.18.0 |
MCR-19-005-1 |
UPDATE |
For ta inferential |
Yes |
No |
| 02/02/2024 |
3.18.0 |
MCR-19-005-1 |
UPDATE |
Ta min |
0 |
|
| 02/02/2024 |
3.18.0 |
MCR-19-005-1 |
UPDATE |
Ta max |
0.05 |
|
| 02/02/2024 |
3.18.0 |
MCR-19-005-1 |
UPDATE |
Focus area |
Managed care |
N/A |
| 11/15/2023 |
3.16.0 |
MCR-17-008-2 |
UPDATE |
Measure name |
% of claim headers with missing OT RX Claim Quantity Actual |
% of claim headers with missing Prescription Quantity Actual |
| 11/15/2023 |
3.16.0 |
MCR-17-008-2 |
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 Encounter: 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 = "3"2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "0" or is missingSTEP 3: Missing OT RX Claim QuantityOf the claims that meet the criteria from STEP 2, further restrict them by the following criteria:1. OT-RX-CLAIM-QUANTITY-ACTUAL is missingSTEP 4: Calculate the percentage for the measureDivide the count of claims from STEP 3 by the count of claims from STEP 2 |
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 Encounter: 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 = "3"2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "0" or is missingSTEP 3: Missing Prescription Quantity ActualOf the claims that meet the criteria from STEP 2, further restrict them by the following criteria:1. PRESCRIPTION-QUANTITY-ACTUAL is missingSTEP 4: Calculate the percentage for the measureDivide the count of claims from STEP 3 by the count of claims from STEP 2 |
| 11/15/2023 |
3.16.0 |
MCR-17-007-4 |
UPDATE |
Measure name |
% of claim headers with OT-RX-CLAIM-QUANTITY-ACTUAL = 1 |
% of claim headers with PRESCRIPTION-QUANTITY-ACTUAL = 1 |
| 11/15/2023 |
3.16.0 |
MCR-17-007-4 |
UPDATE |
Specification |
STEP 1: Active non-duplicate paid RX records during DQ 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 Encounter: 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 = "3”2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "0" or is missingSTEP 3: Drugs, services, or products rendered is 1Of the records that meet the criteria from STEP 2, count line records with1. OT-RX-CLAIM-QUANTITY-ACTUAL = 1STEP 4 : Calculate percentage for measureDivide the count of line records from STEP 3 by the count of line records from STEP 2. |
STEP 1: Active non-duplicate paid RX records during DQ 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 Encounter: 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 = "3”2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "0" or is missingSTEP 3: Drugs, services, or products rendered is 1Of the records that meet the criteria from STEP 2, count line records with1. PRESCRIPTION-QUANTITY-ACTUAL = 1STEP 4 : Calculate percentage for measureDivide the count of line records from STEP 3 by the count of line records from STEP 2. |
| 02/02/2024 |
3.18.0 |
MCR-17-005-1 |
UPDATE |
Priority |
High |
N/A |
| 02/02/2024 |
3.18.0 |
MCR-17-005-1 |
UPDATE |
Category |
Utilization |
N/A |
| 02/02/2024 |
3.18.0 |
MCR-17-005-1 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 02/02/2024 |
3.18.0 |
MCR-17-005-1 |
UPDATE |
For ta inferential |
Yes |
No |
| 02/02/2024 |
3.18.0 |
MCR-17-005-1 |
UPDATE |
Ta min |
0 |
|
| 02/02/2024 |
3.18.0 |
MCR-17-005-1 |
UPDATE |
Ta max |
0.05 |
|
| 02/02/2024 |
3.18.0 |
MCR-17-005-1 |
UPDATE |
Focus area |
Managed care |
N/A |
| 11/15/2023 |
3.16.0 |
MCR-14-024-2 |
UPDATE |
Measure name |
% of claim headers with OT-RX-CLAIM-QUANTITY-ACTUAL = 1 |
% of claim headers with SERVICE-QUANTITY-ACTUAL = 1 |
| 11/15/2023 |
3.16.0 |
MCR-14-022-17 |
UPDATE |
Measure name |
% of claim lines with TYPE-OF-SERVICE = 12, 25, 26 with local service code indicator (PROCDURE-CODE = 10 - 87) |
% of claim lines with TYPE-OF-SERVICE = 12, 25, 26 with local service code indicator (PROCEDURE-CODE-FLAG = 10 - 87) |
| 11/15/2023 |
3.16.0 |
MCR-1-010-5 |
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 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: Medicaid Encounter: 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 = "3"2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "0" or is missingSTEP 3: Patient status of discharged to other institutionOf the claims that meet the criteria from STEP 2, select claims with patient status of other institution:1. PATIENT-STATUS = “2” or “3” or “4” or “5” or “43” or “51” or “61” or “62” or “63” or “64” or “65” or “66” or “70” or “82” or “83” or “84” or “85” or “88” or “89” or “90” or “91” or “92” or “93” or “94” or “95”STEP 4 : Calculate percentage for measureDivide the count of claims from STEP 3 by the count of claims from STEP 2. |
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 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: Medicaid Encounter: 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 = "3"2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "0" or is missingSTEP 3: Patient status of discharged to other institutionOf the claims that meet the criteria from STEP 2, select claims with patient status of other institution:1. PATIENT-STATUS = “02” or “03” or “04” or “05” or “43” or “51” or “61” or “62” or “63” or “64” or “65” or “66” or “70” or “82” or “83” or “84” or “85” or “88” or “89” or “90” or “91” or “92” or “93” or “94” or “95”STEP 4 : Calculate percentage for measureDivide the count of claims from STEP 3 by the count of claims from STEP 2. |
| 11/15/2023 |
3.16.0 |
MCR-1-009-4 |
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 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: Medicaid Encounter: 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 = "3"2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "0" or is missingSTEP 3: Patient status of discharged to homeOf the claims that meet the criteria from STEP 2, select claims with home patient status:1. PATIENT-STATUS = “1” or “6” or “8” or “50” or “81” or “86”STEP 4 : Calculate percentage for measureDivide the count of claims from STEP 3 by the count of claims from STEP 2. |
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 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: Medicaid Encounter: 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 = "3"2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "0" or is missingSTEP 3: Patient status of discharged to homeOf the claims that meet the criteria from STEP 2, select claims with home patient status:1. PATIENT-STATUS = “01” or “06” or “08” or “50” or “81” or “86”STEP 4 : Calculate percentage for measureDivide the count of claims from STEP 3 by the count of claims from STEP 2. |
| 11/15/2023 |
3.16.0 |
MCR-10-024-2 |
UPDATE |
Measure name |
% of claim headers with OT-RX-CLAIM-QUANTITY-ACTUAL = 1 |
% of claim headers with SERVICE-QUANTITY-ACTUAL = 1 |
| 11/15/2023 |
3.16.0 |
MCR-10-024-2 |
UPDATE |
Specification |
STEP 1: Active non-duplicated 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 Encounter: 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 = "3"2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "0" or is missingSTEP 3: Drugs, services, or products rendered is 1Of the records that meet the criteria from STEP 2, count line records with1. OT-RX-CLAIM-QUANTITY-ACTUAL = 1STEP 4 : Calculate percentage for measureDivide the count of line records from STEP 3 by the count of line records from STEP 2. |
STEP 1: Active non-duplicated 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 Encounter: 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 = "3"2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "0" or is missingSTEP 3: Drugs, services, or products rendered is 1Of the records that meet the criteria from STEP 2, count line records with1. SERVICE-QUANTITY-ACTUAL = 1STEP 4 : Calculate percentage for measureDivide the count of line records from STEP 3 by the count of line records from STEP 2. |
| 11/15/2023 |
3.16.0 |
MCR-10-022-17 |
UPDATE |
Measure name |
% of claim lines with TYPE-OF-SERVICE = 12, 25, 26 with local service code indicator (PROCDURE-CODE = 10 - 87) |
% of claim lines with TYPE-OF-SERVICE = 12, 25, 26 with local service code indicator (PROCEDURE-CODE-FLAG = 10 - 87) |
| 11/15/2023 |
3.16.0 |
FFS-9-025-2 |
UPDATE |
Measure name |
% of claim headers with OT-RX-CLAIM-QUANTITY-ACTUAL = 1 |
% of claim headers with SERVICE-QUANTITY-ACTUAL = 1 |
| 11/15/2023 |
3.16.0 |
FFS-9-025-2 |
UPDATE |
Specification |
STEP 1: Active non-duplicate OT records during DQ 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: Drugs, services, or products rendered is 1Of the records that meet the criteria from STEP 2, count line records with1. OT-RX-CLAIM-QUANTITY-ACTUAL = 1STEP 4 : Calculate percentage for measureDivide the count of line records from STEP 3 by the count of line records from STEP 2. |
STEP 1: Active non-duplicate OT records during DQ 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: Drugs, services, or products rendered is 1Of the records that meet the criteria from STEP 2, count line records with1. SERVICE-QUANTITY-ACTUAL = 1STEP 4 : Calculate percentage for measureDivide the count of line records from STEP 3 by the count of line records from STEP 2. |
| 11/15/2023 |
3.16.0 |
FFS-9-023-17 |
UPDATE |
Measure name |
% of claim lines with TYPE-OF-SERVICE = 12, 25, 26 with local service code indicator (PROCDURE-CODE = 10 - 87) |
% of claim lines with TYPE-OF-SERVICE = 12, 25, 26 with local service code indicator (PROCEDURE-CODE-FLAG = 10 - 87) |
| 11/15/2023 |
3.16.0 |
FFS-16-008-2 |
UPDATE |
Measure name |
% of claim headers with missing OT RX Claim Quantity Actual |
% of claim headers with missing Prescription Quantity Actual |
| 11/15/2023 |
3.16.0 |
FFS-16-008-2 |
UPDATE |
Specification |
STEP 1: Active non-duplicate RX records during DQ 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: S-CHIP 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 = "A"2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "0" or is missingSTEP 3: Missing OT RX Claim QuantityOf the claims that meet the criteria from STEP 2, further restrict them by the following criteria:1. OT-RX-CLAIM-QUANTITY-ACTUAL is missingSTEP 4: Calculate the percentage for the measureDivide the count of claims from STEP 3 by the count of claims from STEP 2 |
STEP 1: Active non-duplicate RX records during DQ 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: S-CHIP 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 = "A"2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "0" or is missingSTEP 3: Missing Prescription Quantity ActualOf the claims that meet the criteria from STEP 2, further restrict them by the following criteria:1. PRESCRIPTION-QUANTITY-ACTUAL is missingSTEP 4: Calculate the percentage for the measureDivide the count of claims from STEP 3 by the count of claims from STEP 2 |
| 11/15/2023 |
3.16.0 |
FFS-16-007-4 |
UPDATE |
Measure name |
% of claim headers with OT-RX-CLAIM-QUANTITY-ACTUAL = 1 |
% of claim headers with PRESCRIPTION-QUANTITY-ACTUAL = 1 |
| 02/02/2024 |
3.18.0 |
FFS-16-005-1 |
UPDATE |
Priority |
High |
N/A |
| 02/02/2024 |
3.18.0 |
FFS-16-005-1 |
UPDATE |
Category |
Utilization |
N/A |
| 02/02/2024 |
3.18.0 |
FFS-16-005-1 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 02/02/2024 |
3.18.0 |
FFS-16-005-1 |
UPDATE |
For ta inferential |
Yes |
No |
| 02/02/2024 |
3.18.0 |
FFS-16-005-1 |
UPDATE |
Ta min |
0 |
|
| 02/02/2024 |
3.18.0 |
FFS-16-005-1 |
UPDATE |
Ta max |
0.05 |
|
| 11/15/2023 |
3.16.0 |
FFS-14-008-2 |
UPDATE |
Measure name |
% of claim headers with missing OT RX Claim Quantity Actual |
% of claim headers with missing Prescription Quantity Actual |
| 11/15/2023 |
3.16.0 |
FFS-14-008-2 |
UPDATE |
Specification |
STEP 1: Active non-duplicate RX records during DQ 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 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: Missing OT RX Claim QuantityOf the claims that meet the criteria from STEP 2, further restrict them by the following criteria:1. OT-RX-CLAIM-QUANTITY-ACTUAL is missingSTEP 4: Calculate the percentage for the measureDivide the count of claims from STEP 3 by the count of claims from STEP 2 |
STEP 1: Active non-duplicate RX records during DQ 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 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: Missing Prescription Quantity ActualOf the claims that meet the criteria from STEP 2, further restrict them by the following criteria:1. PRESCRIPTION-QUANTITY-ACTUAL is missingSTEP 4: Calculate the percentage for the measureDivide the count of claims from STEP 3 by the count of claims from STEP 2 |
| 11/15/2023 |
3.16.0 |
FFS-14-007-4 |
UPDATE |
Measure name |
% of claim headers with OT-RX-CLAIM-QUANTITY-ACTUAL = 1 |
% of claim headers with PRESCRIPTION-QUANTITY-ACTUAL = 1 |
| 11/15/2023 |
3.16.0 |
FFS-14-007-4 |
UPDATE |
Specification |
STEP 1: Active non-duplicate paid RX records during DQ 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 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: Drugs, services, or products rendered is 1Of the records that meet the criteria from STEP 2, count line records with1. OT-RX-CLAIM-QUANTITY-ACTUAL = 1STEP 4 : Calculate percentage for measureDivide the count of line records from STEP 3 by the count of line records from STEP 2 |
STEP 1: Active non-duplicate paid RX records during DQ 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 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: Drugs, services, or products rendered is 1Of the records that meet the criteria from STEP 2, count line records with1. PRESCRIPTION-QUANTITY-ACTUAL = 1STEP 4 : Calculate percentage for measureDivide the count of line records from STEP 3 by the count of line records from STEP 2 |
| 02/02/2024 |
3.18.0 |
FFS-14-005-1 |
UPDATE |
Priority |
High |
N/A |
| 02/02/2024 |
3.18.0 |
FFS-14-005-1 |
UPDATE |
Category |
Utilization |
N/A |
| 02/02/2024 |
3.18.0 |
FFS-14-005-1 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 02/02/2024 |
3.18.0 |
FFS-14-005-1 |
UPDATE |
For ta inferential |
Yes |
No |
| 02/02/2024 |
3.18.0 |
FFS-14-005-1 |
UPDATE |
Ta min |
0 |
|
| 02/02/2024 |
3.18.0 |
FFS-14-005-1 |
UPDATE |
Ta max |
0.05 |
|
| 11/15/2023 |
3.16.0 |
FFS-11-024-2 |
UPDATE |
Measure name |
% of claim headers with OT-RX-CLAIM-QUANTITY-ACTUAL = 1 |
% of claim headers with SERVICE-QUANTITY-ACTUAL = 1 |
| 11/15/2023 |
3.16.0 |
FFS-11-022-17 |
UPDATE |
Measure name |
% of claim lines with TYPE-OF-SERVICE = 12, 25, 26 with local service code indicator (PROCDURE-CODE = 10 - 87) |
% of claim lines with TYPE-OF-SERVICE = 12, 25, 26 with local service code indicator (PROCEDURE-CODE-FLAG = 10 - 87) |
| 02/26/2025 |
3.34.0 |
EXP-7-026-3 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-7-026-3 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-7-025-10 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-7-025-10 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-7-024-9 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-7-024-9 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-7-023-8 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-7-023-8 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-7-022-7 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-7-022-7 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-7-021-6 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-7-021-6 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-7-020-5 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-7-020-5 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-7-019-4 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-7-019-4 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-7-018-11 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-7-018-11 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-7-017-18 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-7-017-18 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-7-016-17 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-7-016-17 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-7-015-16 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-7-015-16 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-7-014-15 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-7-014-15 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-7-013-14 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-7-013-14 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-7-012-13 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-7-012-13 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-7-011-12 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-7-011-12 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-7-010-19 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-7-010-19 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-6-027-4 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-6-027-4 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-6-026-11 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-6-026-11 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-6-025-10 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-6-025-10 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-6-024-9 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-6-024-9 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-6-023-8 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-6-023-8 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-6-022-7 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-6-022-7 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-6-021-6 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-6-021-6 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-6-020-5 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-6-020-5 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-6-019-12 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-6-019-12 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-6-018-19 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-6-018-19 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-6-017-18 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-6-017-18 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-6-016-17 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-6-016-17 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-6-015-16 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-6-015-16 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-6-014-15 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-6-014-15 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-6-013-14 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-6-013-14 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-6-012-13 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-6-012-13 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-6-011-20 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-6-011-20 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-5-019-9 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-5-019-9 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-5-018-8 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-5-018-8 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-5-017-7 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-5-017-7 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-5-016-6 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-5-016-6 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-5-015-5 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-5-015-5 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-5-014-4 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-5-014-4 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-5-013-3 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-5-013-3 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-5-012-2 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-5-012-2 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-5-011-1 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-5-011-1 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-2-019-11 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-2-019-11 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-2-018-10 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-2-018-10 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-2-017-9 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-2-017-9 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-2-016-8 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-2-016-8 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-2-015-7 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-2-015-7 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-2-014-6 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-2-014-6 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-2-013-5 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-2-013-5 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-2-012-4 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-2-012-4 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-2-011-3 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-2-011-3 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-19-016-2 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-19-016-2 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-19-015-8 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-19-015-8 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-19-014-7 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-19-014-7 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-19-013-6 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-19-013-6 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-19-012-5 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-19-012-5 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-19-011-4 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-19-011-4 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-19-010-3 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-19-010-3 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-19-009-1 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-19-009-1 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-17-016-2 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-17-016-2 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-17-015-8 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-17-015-8 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-17-014-7 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-17-014-7 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-17-013-6 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-17-013-6 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-17-012-5 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-17-012-5 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-17-011-4 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-17-011-4 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-17-010-3 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-17-010-3 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-17-009-1 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-17-009-1 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-16-019-6 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-16-019-6 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-16-018-12 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-16-018-12 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-16-017-11 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-16-017-11 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-16-016-10 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-16-016-10 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-16-015-9 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-16-015-9 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-16-014-8 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-16-014-8 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-16-013-7 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-16-013-7 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-16-012-5 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-16-012-5 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-154-5 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-154-5 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-153-3 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-153-3 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-151-77 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-151-77 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-151-76 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-151-76 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-150-75 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-150-75 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-149-74 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-149-74 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-148-73 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-148-73 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-147-72 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-147-72 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-146-71 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-146-71 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-145-70 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-145-70 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-144-68 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-144-68 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-143-67 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-143-67 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-142-66 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-142-66 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-141-65 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-141-65 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-140-64 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-140-64 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-139-63 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-139-63 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-138-62 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-138-62 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-137-61 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-137-61 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-136-60 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-136-60 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-134-57 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-134-57 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-133-56 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-133-56 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-132-55 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-132-55 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-131-54 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-131-54 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-130-53 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-130-53 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-129-52 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-129-52 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-128-51 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-128-51 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-127-50 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-127-50 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-126-49 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-126-49 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-125-47 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-125-47 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-124-46 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-124-46 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-123-45 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-123-45 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-122-44 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-122-44 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-121-43 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-121-43 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-120-42 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-120-42 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-119-41 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-119-41 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-118-40 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-118-40 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-117-38 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-117-38 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-116-37 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-116-37 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-115-36 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-115-36 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-114-35 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-114-35 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-113-34 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-113-34 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-112-32 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-112-32 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-111-31 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-111-31 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-110-30 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-110-30 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-109-29 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-109-29 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-108-28 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-108-28 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-107-27 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-107-27 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-106-26 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-106-26 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-105-25 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-105-25 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-104-23 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-104-23 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-103-22 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-103-22 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-102-21 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-102-21 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-101-20 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-101-20 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-100-19 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-100-19 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-099-18 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-099-18 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-098-17 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-098-17 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-097-16 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-097-16 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-096-15 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-096-15 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-095-14 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-095-14 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-094-12 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-094-12 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-093-11 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-093-11 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-092-10 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-092-10 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-091-9 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-091-9 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-089-7 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-089-7 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-088-6 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-088-6 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-087-4 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-087-4 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-086-2 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-086-2 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-085-1 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-085-1 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-084-69 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-084-69 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-083-58 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-083-58 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-082-48 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-082-48 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-081-39 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-081-39 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-080-33 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-080-33 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-079-24 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-079-24 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-078-13 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-15-078-13 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 06/19/2024 |
3.27.0 |
EXP-13-004-2 |
UPDATE |
Category |
Expenditures |
N/A |
| 06/19/2024 |
3.27.0 |
EXP-13-004-2 |
UPDATE |
Ta min |
0 |
|
| 06/19/2024 |
3.27.0 |
EXP-13-004-2 |
UPDATE |
Ta max |
0.1 |
|
| 02/26/2025 |
3.34.0 |
EXP-12-157-8 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-157-8 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-156-6 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-156-6 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-155-80 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-155-80 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-154-79 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-154-79 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-153-78 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-153-78 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-152-77 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-152-77 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-151-76 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-151-76 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-150-75 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-150-75 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-149-74 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-149-74 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-148-73 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-148-73 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-147-71 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-147-71 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-146-70 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-146-70 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-145-69 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-145-69 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-144-68 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-144-68 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-143-67 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-143-67 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-142-66 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-142-66 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-141-65 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-141-65 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-140-64 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-140-64 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-139-63 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-139-63 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-137-60 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-137-60 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-136-59 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-136-59 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-135-58 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-135-58 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-134-57 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-134-57 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-133-56 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-133-56 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-132-55 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-132-55 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-131-54 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-131-54 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-130-53 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-130-53 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-129-52 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-129-52 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-128-50 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-128-50 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-127-49 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-127-49 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-126-48 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-126-48 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-125-47 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-125-47 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-124-46 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-124-46 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-123-45 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-123-45 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-122-44 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-122-44 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-121-43 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-121-43 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-120-41 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-120-41 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-119-40 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-119-40 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-118-39 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-118-39 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-117-38 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-117-38 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-116-37 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-116-37 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-115-35 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-115-35 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-114-34 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-114-34 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-113-33 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-113-33 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-112-32 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-112-32 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-111-31 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-111-31 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-110-30 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-110-30 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-109-29 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-109-29 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-108-28 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-108-28 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-107-26 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-107-26 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-106-25 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-106-25 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-105-24 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-105-24 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-104-23 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-104-23 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-103-22 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-103-22 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-102-21 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-102-21 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-101-20 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-101-20 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-100-19 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-100-19 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-099-18 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-099-18 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-098-17 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-098-17 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-097-15 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-097-15 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-096-14 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-096-14 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-095-13 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-095-13 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-094-12 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-094-12 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-092-10 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-092-10 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-091-9 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-091-9 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-090-7 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-090-7 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-089-5 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-089-5 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-088-4 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-088-4 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-087-72 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-087-72 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-086-61 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-086-61 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-085-51 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-085-51 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-084-42 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-084-42 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-083-36 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-083-36 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-082-27 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-082-27 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-081-16 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-081-16 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-080-3 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-12-080-3 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-159-10 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-159-10 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-158-8 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-158-8 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-157-82 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-157-82 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-156-81 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-156-81 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-155-80 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-155-80 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-154-79 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-154-79 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-153-78 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-153-78 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-152-77 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-152-77 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-151-76 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-151-76 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-150-75 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-150-75 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-149-73 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-149-73 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-148-72 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-148-72 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-147-71 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-147-71 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-146-70 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-146-70 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-145-69 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-145-69 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-144-68 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-144-68 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-143-67 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-143-67 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-142-66 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-142-66 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-141-65 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-141-65 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-139-62 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-139-62 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-138-61 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-138-61 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-137-60 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-137-60 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-136-59 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-136-59 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-135-58 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-135-58 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-134-57 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-134-57 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-133-56 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-133-56 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-132-55 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-132-55 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-131-54 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-131-54 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-130-52 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-130-52 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-129-51 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-129-51 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-128-50 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-128-50 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-127-49 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-127-49 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-126-48 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-126-48 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-125-47 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-125-47 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-124-46 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-124-46 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-123-45 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-123-45 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-122-43 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-122-43 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-121-42 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-121-42 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-120-41 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-120-41 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-119-40 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-119-40 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-118-39 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-118-39 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-117-37 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-117-37 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-116-36 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-116-36 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-115-35 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-115-35 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-114-34 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-114-34 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-113-33 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-113-33 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-112-32 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-112-32 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-111-31 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-111-31 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-110-30 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-110-30 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-109-28 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-109-28 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-108-27 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-108-27 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-107-26 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-107-26 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-106-25 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-106-25 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-105-24 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-105-24 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-104-23 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-104-23 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-103-22 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-103-22 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-102-21 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-102-21 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-101-20 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-101-20 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-100-19 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-100-19 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-099-17 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-099-17 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-098-16 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-098-16 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-097-15 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-097-15 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-096-14 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-096-14 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-094-12 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-094-12 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-093-11 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-093-11 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-092-9 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-092-9 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-091-7 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-091-7 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-090-6 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-090-6 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-089-74 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-089-74 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-088-63 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-088-63 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-087-53 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-087-53 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-086-44 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-086-44 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-085-38 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-085-38 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-084-29 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-084-29 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-083-18 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-11-083-18 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-1-022-13 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-1-022-13 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-1-021-12 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-1-021-12 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-1-020-11 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-1-020-11 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-1-019-10 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-1-019-10 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-1-018-9 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-1-018-9 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-1-017-8 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-1-017-8 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-1-016-7 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-1-016-7 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-1-015-6 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-1-015-6 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-1-014-5 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-1-014-5 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-10-025-1 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-10-025-1 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-10-024-8 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-10-024-8 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-10-023-7 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-10-023-7 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-10-022-6 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-10-022-6 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-10-021-5 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-10-021-5 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-10-020-4 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-10-020-4 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-10-019-3 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-10-019-3 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-10-018-2 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-10-018-2 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-10-017-9 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-10-017-9 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-10-016-16 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-10-016-16 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-10-015-15 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-10-015-15 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-10-014-14 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-10-014-14 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-10-013-13 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-10-013-13 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-10-012-12 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-10-012-12 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-10-011-11 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-10-011-11 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-10-010-10 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-10-010-10 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-10-009-17 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EXP-10-009-17 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 02/26/2025 |
3.34.0 |
EL-6-019-19 |
UPDATE |
Annotation |
N/A |
Count the number of 'Other - specific CMS approval duals' |
| 02/26/2025 |
3.34.0 |
EL-6-019-19 |
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: 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: Count of number of 'Other - specific CMS approval duals'Of the MSIS IDs which meet the criteria from STEP 2, count the number with 1. DUAL-ELIGIBLE-CODE = '09' |
| 02/26/2025 |
3.34.0 |
EL-6-017-17 |
UPDATE |
Annotation |
N/A |
Count the number of 'QI-1 Duals' |
| 02/26/2025 |
3.34.0 |
EL-6-017-17 |
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: 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: Count of number of 'QI-1 Duals'Of the MSIS IDs which meet the criteria from STEP 2, count the number with 1. DUAL-ELIGIBLE-CODE = '06' |
| 02/26/2025 |
3.34.0 |
EL-6-016-16 |
UPDATE |
Annotation |
N/A |
Count the number of 'QDWI Duals' |
| 02/26/2025 |
3.34.0 |
EL-6-016-16 |
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: 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: Count of number of 'QDWI Duals'Of the MSIS IDs which meet the criteria from STEP 2, count the number with 1. DUAL-ELIGIBLE-CODE = '05' |
| 02/26/2025 |
3.34.0 |
EL-6-015-15 |
UPDATE |
Annotation |
N/A |
Count the number of 'SLMB Plus Duals' |
| 02/26/2025 |
3.34.0 |
EL-6-015-15 |
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: 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: Count of number of 'SLMB Plus Duals'Of the MSIS IDs which meet the criteria from STEP 2, count the number with 1. DUAL-ELIGIBLE-CODE = '04' |
| 02/26/2025 |
3.34.0 |
EL-6-014-14 |
UPDATE |
Annotation |
N/A |
Count the number of 'SLMB Only Duals' |
| 02/26/2025 |
3.34.0 |
EL-6-014-14 |
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: 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: Count of number of 'SLMB Only Duals'Of the MSIS IDs which meet the criteria from STEP 2, count the number with 1. DUAL-ELIGIBLE-CODE = '03' |
| 02/26/2025 |
3.34.0 |
EL-6-013-13 |
UPDATE |
Annotation |
N/A |
Count the number of 'QMB Plus Duals' |
| 02/26/2025 |
3.34.0 |
EL-6-013-13 |
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: 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: Count of number of 'QMB Plus Duals'Of the MSIS IDs which meet the criteria from STEP 2, count the number with 1. DUAL-ELIGIBLE-CODE = '02' |
| 02/26/2025 |
3.34.0 |
EL-6-012-12 |
UPDATE |
Annotation |
N/A |
Count the number of 'QMB Only Duals' |
| 02/26/2025 |
3.34.0 |
EL-6-012-12 |
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: 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: Count of number of 'QMB Only Duals'Of the MSIS IDs which meet the criteria from STEP 2, count the number with 1. DUAL-ELIGIBLE-CODE = '01' |
| 06/19/2024 |
3.27.0 |
EL-5-001-3 |
UPDATE |
Longitudinal threshold |
TBD |
N/A |
| 06/19/2024 |
3.27.0 |
EL-3-002-7 |
UPDATE |
Priority |
High |
N/A |
| 06/19/2024 |
3.27.0 |
EL-3-002-7 |
UPDATE |
Category |
Beneficiary eligibility |
N/A |
| 06/19/2024 |
3.27.0 |
EL-3-002-7 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 06/19/2024 |
3.27.0 |
EL-3-002-7 |
UPDATE |
For ta inferential |
Yes |
No |
| 06/19/2024 |
3.27.0 |
EL-3-002-7 |
UPDATE |
Ta min |
0.95 |
|
| 06/19/2024 |
3.27.0 |
EL-3-002-7 |
UPDATE |
Ta max |
1 |
|
| 06/19/2024 |
3.27.0 |
EL-3-002-7 |
UPDATE |
Annotation |
Calculate the percentage of eligibles in ELIGIBILITY-GROUP QMB, QDWI, SLMB or QI (23 through 26) with valid DUAL-ELIGIBLE CODE 01 through 10 |
N/A |
| 06/19/2024 |
3.27.0 |
EL-3-002-7 |
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: 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 month 3a. 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: Eligibility Group: QMB, QDWI, SLMB or QIOf the MSIS IDs that meet the criteria from STEP 2, further refine the population by keeping records with ELIGIBLE-GROUP=“23” or “24” or “25” or “26” STEP 4: Dual eligibleOf the MSIS IDs that meet the criteria from STEP 3, further refine the population by keeping records with DUAL-ELIGIBLE-CODE=“01” or “02” or “03” or “04” or “05” or “06” or “08” or “09” or “10” STEP 5: Calculate percentage for measureDIVIDE the count of MSIS IDs from STEP 4 by the count of MSIS IDs from STEP 3 |
N/A |
| 11/15/2023 |
3.16.0 |
EL-3-001-1 |
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 month2. ENROLLMENT-END-DATE >= last day of the DQ report 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: Unique Valid CodesOf the MSIS IDs that meet the criteria from STEP 2, select those with a valid value for ELIGIBILITY-GROUP:1. ELIGIBILITY-GROUP = "1" or "2" or "3" or "4" or "5" or "6" or "7" or "8" or "9" or "72" or "73" or "74" or "75" or "11" or "12" or "13" or "14" or "15" or "16" or "17" or "18" or "19" or "20" or "21" or "22" or "23" or "24" or "25" or "26" or "27" or "28" or "29" or "30" or "31" or "32" or "33" or "34" or "35" or "36" or "37" or "38" or "39" or "40" or "41" or "42" or "43" or "44" or "45" or "46" or "47" or "48" or "49" or "50" or "51" or "52" or "53" or "54" or "55" or "56" or "59" or "60" or "61" or "62" or "63" or "64" or "65" or "66" or "67" or "68" or "69" or "70" or "71" or "76"2. Remove any duplicates, so each MSIS ID only appears once. |
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 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: Unique Valid CodesOf the MSIS IDs that meet the criteria from STEP 2, select those with a valid value for ELIGIBILITY-GROUP:1. ELIGIBILITY-GROUP = "01" or "02" or "03" or "04" or "05" or "06" or "07" or "08" or "09" or "72" or "73" or "74" or "75" or "11" or "12" or "13" or "14" or "15" or "16" or "17" or "18" or "19" or "20" or "21" or "22" or "23" or "24" or "25" or "26" or "27" or "28" or "29" or "30" or "31" or "32" or "33" or "34" or "35" or "36" or "37" or "38" or "39" or "40" or "41" or "42" or "43" or "44" or "45" or "46" or "47" or "48" or "49" or "50" or "51" or "52" or "53" or "54" or "55" or "56" or "59" or "60" or "61" or "62" or "63" or "64" or "65" or "66" or "67" or "68" or "69" or "70" or "71" or "76"2. Remove any duplicates, so each MSIS ID only appears once. |
| 06/19/2024 |
3.27.0 |
EL-2-001-1 |
UPDATE |
Longitudinal threshold |
TBD |
N/A |
| 06/19/2024 |
3.27.0 |
EL-1-009-8 |
UPDATE |
Longitudinal threshold |
TBD |
N/A |
| 06/19/2024 |
3.27.0 |
EL-1-008-7 |
UPDATE |
Longitudinal threshold |
TBD |
N/A |
| 06/19/2024 |
3.27.0 |
EL-1-007-5 |
UPDATE |
Longitudinal threshold |
TBD |
N/A |
| 06/19/2024 |
3.27.0 |
EL-1-006-4 |
UPDATE |
Longitudinal threshold |
TBD |
N/A |
| 11/15/2023 |
3.16.0 |
EL-1-001-1 |
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: Primary demographics on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 1, join to segment PRIMARY-DEMOGRAPHICS-ELG00002 by keeping records that satisfy the following criteria:1a. PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE <= last day of the DQ report month2a. PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE >= last day of the DQ report month OR missingOR1b. PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE is missing2b. PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE is missingSTEP 3: Non-missing SSNOf the MSIS IDs that meet the criteria from STEP 2, further refine the population by keeping records with non-missing SSNSTEP 4: Non-missing MSIS IDOf the MSIS IDs that meet the criteria from STEP 3, further refine the population by keeping records with non-missing MSIS-IDENTIFICATION-NUMSTEP 5: Calculate percentage for measureDIVIDE the count of MSIS IDs from STEP 4 by the count of MSIS IDs from STEP 1 |
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-DEMOGRAPHICS-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: Non-missing SSNOf the MSIS IDs that meet the criteria from STEP 2, further refine the population by keeping records with non-missing SSNSTEP 4: Non-missing MSIS IDOf the MSIS IDs that meet the criteria from STEP 3, further refine the population by keeping records with non-missing MSIS-IDENTIFICATION-NUMSTEP 5: Calculate percentage for measureDIVIDE the count of MSIS IDs from STEP 4 by the count of MSIS IDs from STEP 1 |
| 03/27/2024 |
3.22.0 |
EL-10-004-5 |
UPDATE |
Measure name |
% of MSIS IDs with restricted benefit (RESTRICTED-BENEFITS-CODE = 02 through 06) enrolled in comprehensive managed care (MANAGED-CARE-PLAN-TYPE = 01) |
% of MSIS IDs with restricted benefit (RESTRICTED-BENEFITS-CODE = 02, 03, or 06) enrolled in comprehensive managed care (MANAGED-CARE-PLAN-TYPE = 01) |
| 03/27/2024 |
3.22.0 |
EL-10-004-5 |
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: 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: Restricted benefit eligiblesOf the MSIS IDs that meet the criteria from STEP 2, further refine the population using RESTRICTED-BENEFITS-CODE = (“2” or “3” or “4” or “5” or “6”)STEP 4: Managed care enrollment on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 3, join to 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 5: Identify individuals in a comprehensive managed care planSelect MSIS IDs from STEP 4 where MANAGED-CARE-PLAN-TYPE = "01"STEP 6: Calculate percentageDivide the count of unique MSIS IDs from STEP 5 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: 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: Restricted benefit eligiblesOf the MSIS IDs that meet the criteria from STEP 2, further refine the population using RESTRICTED-BENEFITS-CODE = (“2” or “3” or “6”)STEP 4: Managed care enrollment on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 3, join to 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 5: Identify individuals in a comprehensive managed care planSelect MSIS IDs from STEP 4 where MANAGED-CARE-PLAN-TYPE = "01"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 |
EL-10-001-1 |
UPDATE |
Longitudinal threshold |
TBD |
N/A |
| 11/15/2023 |
3.16.0 |
ALL-2-003-3 |
UPDATE |
Specification |
STEP 1: 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: State plan 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 STATE-PLAN-OPTION-PARTICIPATION-ELG00011 by keeping records that satisfy the following criteria:1a. STATE-PLAN-OPTION-EFF-DATE <= last day of the DQ report month2a. STATE-PLAN-OPTION-END-DATE >= last day of the DQ report month OR missingOR1b. STATE-PLAN-OPTION-EFF-DATE is missing2b. STATE-PLAN-OPTION-END-DATE is missingSTEP 3: 1915(i) eligiblesOf the MSIS-IDs that meet the criteria from STEP 2, further refine the population by keeping records that satisfy the following criteria:STATE-PLAN-OPTION-TYPE = '02'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 FFS and Encounter: Original, Non-Crossover, Paid ClaimsOf the claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "1" or "3" 2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "0" or is missingSTEP 6: Eligibles with OT claimsOf the MSIS-IDs from STEP 3, count the number which also appear in the claims from STEP 5STEP 7: Calculate percentage for measureDivide the number of MSIS-IDs from STEP 6 by the number of MSIS-IDs from STEP 3 |
STEP 1: 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: State plan 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 STATE-PLAN-OPTION-PARTICIPATION-ELG00011 by keeping records that satisfy the following criteria:1a. STATE-PLAN-OPTION-EFF-DATE <= last day of the DQ report month2a. STATE-PLAN-OPTION-END-DATE >= last day of the DQ report month OR missingOR1b. STATE-PLAN-OPTION-EFF-DATE is missing2b. STATE-PLAN-OPTION-END-DATE is missingSTEP 3: 1915(i) eligiblesOf the MSIS-IDs that meet the criteria from STEP 2, further refine the population by keeping records that satisfy the following criteria:STATE-PLAN-OPTION-TYPE = '02'STEP 4: 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-ADJUSTMENT-IND.STEP 5: Medicaid FFS and Encounter: Original, Non-Crossover, Paid ClaimsOf the claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "1" or "3" 2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "0" or is missingSTEP 6: Eligibles with OT claimsOf the MSIS-IDs from STEP 3, count the number which also appear in the claims from STEP 5STEP 7: Calculate percentage for measureDivide the number of MSIS-IDs from STEP 6 by the number of MSIS-IDs from STEP 3 |
| 11/15/2023 |
3.16.0 |
ALL-2-002-2 |
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: State plan 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 STATE-PLAN-OPTION-PARTICIPATION-ELG00011 by keeping records that satisfy the following criteria:1a. STATE-PLAN-OPTION-EFF-DATE <= last day of the DQ report month2a. STATE-PLAN-OPTION-END-DATE >= last day of the DQ report month OR missingOR1b. STATE-PLAN-OPTION-EFF-DATE is missing2b. STATE-PLAN-OPTION-END-DATE is missingSTEP 3: Community First ChoiceOf the MSIS-IDs that meet the criteria from STEP 2, further refine the population by keeping records that satisfy the following criteria:STATE-PLAN-OPTION-TYPE = '01'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 FFS and Encounter: Original, Non-Crossover, Paid ClaimsOf the claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "1" or "3" 2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "0" or is missingSTEP 6: Eligibles with OT claimsOf the MSIS-IDs from STEP 3, count the number which also appear in the claims from STEP 5STEP 7: Calculate percentage for measureDivide the number of MSIS-IDs from STEP 6 by the number of 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: State plan 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 STATE-PLAN-OPTION-PARTICIPATION-ELG00011 by keeping records that satisfy the following criteria:1a. STATE-PLAN-OPTION-EFF-DATE <= last day of the DQ report month2a. STATE-PLAN-OPTION-END-DATE >= last day of the DQ report month OR missingOR1b. STATE-PLAN-OPTION-EFF-DATE is missing2b. STATE-PLAN-OPTION-END-DATE is missingSTEP 3: Community First ChoiceOf the MSIS-IDs that meet the criteria from STEP 2, further refine the population by keeping records that satisfy the following criteria:STATE-PLAN-OPTION-TYPE = '01'STEP 4: 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-ADJUSTMENT-IND.STEP 5: Medicaid FFS and Encounter: Original, Non-Crossover, Paid ClaimsOf the claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "1" or "3" 2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "0" or is missingSTEP 6: Eligibles with OT claimsOf the MSIS-IDs from STEP 3, count the number which also appear in the claims from STEP 5STEP 7: Calculate percentage for measureDivide the number of MSIS-IDs from STEP 6 by the number of MSIS-IDs from STEP 3 |
| 09/12/2024 |
3.29.0 |
TPL.006.085 |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
TPL.006.084 |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
TPL.005.069 |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
TPL.005.068 |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20']6. Value must occur on or before individual's Date of Death (ELG.002.025) when populated |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20]6. Value must occur on or before individual's Date of Death (ELG.002.025) when populated |
| 09/12/2024 |
3.29.0 |
TPL.005.066 |
UPDATE |
Definition |
A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
| 09/12/2024 |
3.29.0 |
TPL.004.060 |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
TPL.004.059 |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
TPL.004.058 |
UPDATE |
Coding requirement |
1. Value must be in Coverage Type List (VVL).2. Value must be 2 characters3. Mandatory |
1. Value must be in Coverage Type List (VVL)2. Value must be 2 characters3. Mandatory |
| 09/12/2024 |
3.29.0 |
TPL.003.049 |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99']6. When associated Date of Death (ELG.002.025) is populated, data element value must be less than or equal to Date of Death |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99]6. When associated Date of Death (ELG.002.025) is populated, data element value must be less than or equal to Date of Death |
| 09/12/2024 |
3.29.0 |
TPL.003.048 |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
TPL.003.038 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
TPL.003.089 |
UPDATE |
Coding requirement |
1. Value must be in Coverage Type List (VVL).2. Value must be 2 characters3. Mandatory |
1. Value must be in Coverage Type List (VVL)2. Value must be 2 characters3. Mandatory |
| 09/12/2024 |
3.29.0 |
TPL.003.032 |
UPDATE |
Definition |
A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
| 09/12/2024 |
3.29.0 |
TPL.002.026 |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
TPL.002.025 |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20']6. Value must be equal to or less than the individual's Date of Death (ELG.002.025) |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20]6. Value must be equal to or less than the individual's Date of Death (ELG.002.025) |
| 09/12/2024 |
3.29.0 |
TPL.002.020 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in TPL Health Insurance Coverage Indicator List (VVL)4. Mandatory5. When value equals '1', there must be one corresponding TPL Medicaid Eligible Person Health Insurance Coverage Information (TPL.003) segment with the same MSIS ID. |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in TPL Health Insurance Coverage Indicator List (VVL)4. Mandatory5. When value equals "1", there must be one corresponding TPL Medicaid Eligible Person Health Insurance Coverage Information (TPL.003) segment with the same MSIS ID. |
| 09/12/2024 |
3.29.0 |
TPL.002.019 |
UPDATE |
Definition |
A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
| 09/12/2024 |
3.29.0 |
TPL.001.011 |
UPDATE |
Coding requirement |
1. For production files, value must be equal to 'P'2. Value must be in File Status Indicator List (VVL)3. Value must be 1 character4. Mandatory |
1. For production files, value must be equal to "P"2. Value must be in File Status Indicator List (VVL)3. Value must be 1 character4. Mandatory |
| 09/12/2024 |
3.29.0 |
TPL.001.007 |
UPDATE |
Coding requirement |
1. Value must be in State Code List (VVL)2. Value must be 2 characters3. Mandatory4. Value must be the same for all records |
1. Value must be in State Code List (VVL)2. Value must be 2 characters3. Mandatory |
| 09/12/2024 |
3.29.0 |
TPL.001.006 |
UPDATE |
Coding requirement |
1. Value must equal 'TPL-FILE'2. Mandatory |
1. Value must equal "TPL-FILE"2. Mandatory |
| 09/12/2024 |
3.29.0 |
PRV.010.131 |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in[18,19,20,99] |
| 09/12/2024 |
3.29.0 |
PRV.010.130 |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
PRV.009.122 |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
PRV.009.121 |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
PRV.008.112 |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
PRV.008.111 |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
PRV.007.099 |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
PRV.007.098 |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
PRV.006.091 |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
PRV.006.090 |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
PRV.006.089 |
UPDATE |
Coding requirement |
1. If associated Provider Classification Type equals 1, value must be in Provider Taxonomy List (VVL)2. If associated Provider Classification Type equals 2, value must be in Provider Specialty List (VVL)3. If associated Provider Classification Type equals 3, value must be in Provider Type Code List (VVL)4. If associated Provider Classification Type equals 4, value must be in Provider Authorized Category of Service Code List (VVL)5. Value must be 20 characters or less6. Mandatory |
1. If associated Provider Classification Type equals "1", value must be in Provider Taxonomy List (VVL)2. If associated Provider Classification Type equals 2, value must be in Provider Specialty List (VVL)3. If associated Provider Classification Type equals "3", value must be in Provider Type Code List (VVL)4. If associated Provider Classification Type equals "4", value must be in Provider Authorized Category of Service Code List (VVL)5. Value must be 20 characters or less6. Mandatory |
| 09/12/2024 |
3.29.0 |
PRV.006.088 |
UPDATE |
Definition |
A code to identify the schema used in the Provider Classification Code field to categorize providers. See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Provider Classification Type and Provider Classification Code in the T-MSIS Provider File" https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/98581 . A provider may be reported with multiple active record segments with the same Provider Classification Type if different Provider Classification Code values apply. |
A code to identify the schema used in the Provider Classification Code field to categorize providers. See T-MSIS Guidance Document, 'CMS Guidance: Best Practice for Reporting Provider Classification Type and Provider Classification Code in the T-MSIS Provider File' https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/98581 . A provider may be reported with multiple active record segments with the same Provider Classification Type if different Provider Classification Code values apply. |
| 09/12/2024 |
3.29.0 |
PRV.005.080 |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
PRV.005.079 |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
PRV.005.078 |
UPDATE |
Coding requirement |
1. Value must not contain a pipe or asterisk symbol2. (State-specific Medicaid Provider) if associated Provider Identifier Type (PRV.005.077) value is equal to 1, then value must equal (PRV.005.073) Submitting State3. (NPI) if associated Provider Identifier Type (PRV.005.077) value is equal to 2, then value must equal 'NPI'4. (Medicare) if associated Provider Identifier Type (PRV.005.077) value is equal to 3, then value must equal 'CMS'5. (NCPDP) if associated Provider Identifier Type (PRV.005.077) value is equal to 4, then value must equal 'NCPDP'6. (Federal Tax ID) if associated Provider Identifier Type (PRV.005.077) value is equal to 5, then value must equal 'IRS'7. (SSN) if associated Provider Identifier Type (PRV.005.077) value is equal to 7, then value must be equal to 'SSA'8. Value must be 18 characters or less9. Mandatory |
1. Value must not contain a pipe or asterisk symbol2. (State-specific Medicaid Provider) if associated Provider Identifier Type (PRV.005.077) value is equal to 1, then value must equal (PRV.005.073) Submitting State3. (NPI) if associated Provider Identifier Type (PRV.005.077) value is equal to "2", then value must equal "NPI"4. (Medicare) if associated Provider Identifier Type (PRV.005.077) value is equal to "3", then value must equal "CMS"5. (NCPDP) if associated Provider Identifier Type (PRV.005.077) value is equal to "4", then value must equal "NCPDP"6. (Federal Tax ID) if associated Provider Identifier Type (PRV.005.077) value is equal to "5", then value must equal "IRS"7. (SSN) if associated Provider Identifier Type (PRV.005.077) value is equal to "7", then value must be equal to "SSA"8. Value must be 18 characters or less9. Mandatory |
| 09/12/2024 |
3.29.0 |
PRV.005.077 |
UPDATE |
Coding requirement |
1. Value must be in Provider Identifier Type List (VVL)2. Mandatory3. Value must be 1 character4. When value equals '2', the associated Provider Identifier (PRV.005.081) must be a valid NPI |
1. Value must be in Provider Identifier Type List (VVL)2. Mandatory3. Value must be 1 character4. When value equals "2", the associated Provider Identifier (PRV.005.081) must be a valid NPI |
| 09/12/2024 |
3.29.0 |
PRV.004.068 |
UPDATE |
Coding requirement |
1. Value must not contain a pipe or asterisk symbol2. Value must be 60 characters or less3. (required) if associated License or Accreditation Number (PRV.004.069) value is populated, then value is mandatory and must be provided4. Mandatory5. Value must equal 'DEA' when associated License Type equals '2' |
1. Value must not contain a pipe or asterisk symbol2. Value must be 60 characters or less3. (required) if associated License or Accreditation Number (PRV.004.069) value is populated, then value is mandatory and must be provided4. Mandatory5. Value must equal "DEA" when associated License Type equals "2" |
| 09/12/2024 |
3.29.0 |
PRV.004.066 |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
PRV.004.065 |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
PRV.003.054 |
UPDATE |
Coding requirement |
1. Must contain the '@' symbol2. May contain uppercase and lowercase Latin letters A to Z and a to z3. May contain digits 0-94. Must contain a dot '.' that is not the first or last character and provided that it does not appear consecutively5. Value must be 60 characters or less6. Situational |
1. Must contain the "@" symbol2. May contain uppercase and lowercase Latin letters A to Z and a to z3. May contain digits 0-94. Must contain a dot "." that is not the first or last character and provided that it does not appear consecutively5. Value must be 60 characters or less6. Situational |
| 09/12/2024 |
3.29.0 |
PRV.003.045 |
UPDATE |
Data element name text |
Provider Location & Contact Info End Date |
Provider Location Contact Info End Date |
| 09/12/2024 |
3.29.0 |
PRV.003.045 |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
PRV.003.044 |
UPDATE |
Data element name text |
Provider Location & Contact Info Effective Date |
Provider Location Contact Info Effective Date |
| 09/12/2024 |
3.29.0 |
PRV.003.044 |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
PRV.002.032 |
UPDATE |
Coding requirement |
1. Value must be in Ownership Code List (VVL)2. Value must be 2 characters3. Conditional4. Value is mandatory when associated Facility Group Individual Code (PRV.002.026) is in ['01, '02'] (organization) |
1. Value must be in Ownership Code List (VVL)2. Value must be 2 characters3. Conditional4. Value is mandatory when associated Facility Group Individual Code (PRV.002.026) is in [01,02] (organization) |
| 02/20/2025 |
3.34.0 |
PRV.002.031 |
UPDATE |
Definition |
Either individual's biological sex or their self-identified sex. |
The individual's biological sex assigned at birth. |
| 09/12/2024 |
3.29.0 |
PRV.002.027 |
UPDATE |
Coding requirement |
1. Value must be in Teaching Indicator List (VVL)2. Value must be 1 character3. Value must be '0' when Facility Group Individual Code (PRV.002.026) equals '02' or '03'4. Conditional |
1. Value must be in Teaching Indicator List (VVL)2. Value must be 1 character3. Value must be "0" when Facility Group Individual Code (PRV.002.026) in [02,03]4. Conditional |
| 09/12/2024 |
3.29.0 |
PRV.002.026 |
UPDATE |
Coding requirement |
1. Value must be in Facility Group Individual Code List (VVL)2. Value must be 2 characters3. Mandatory4. (individual) if value equals '03', then Provider First Name (PRV.002.028) must be populated5. (organization) if value does not equal '03', then Provider Middle Initial (PRV.002.029) must not be populated6. (individual) if value equals '03', then Provider Last Name (PRV.002.030) must be populated7. (individual) if value equals '03', then Provider Sex (PRV.002.031) must be populated8. (individual) if value equals '03', then Provider Date of Birth (PRV.002.034) must be populated9. (organization) if value equals '01' or '02', then Provider Date of Death (PRV.002.035) must not be populated10. (individual) if value equals '03', then there must be one Provider Identifier (PRV.005.081) populated with an associated Provider Identifier Type (PRV.005.077) equal to ‘2’ (NPI) |
1. Value must be in Facility Group Individual Code List (VVL)2. Value must be 2 characters3. Mandatory4. (individual) if value equals "03", then Provider First Name (PRV.002.028) must be populated5. (organization) if value does not equal "03", then Provider Middle Initial (PRV.002.029) must not be populated6. (individual) if value equals "03", then Provider Last Name (PRV.002.030) must be populated7. (individual) if value equals "03", then Provider Sex (PRV.002.031) must be populated8. (individual) if value equals "03", then Provider Date of Birth (PRV.002.034) must be populated9. (organization) if value is in [01,02], then Provider Date of Death (PRV.002.035) must not be populated10. (individual) if value equals "03", then there must be one Provider Identifier (PRV.005.081) populated with an associated Provider Identifier Type (PRV.005.077) equal to "2" (NPI) |
| 09/12/2024 |
3.29.0 |
PRV.002.021 |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
PRV.002.020 |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
PRV.001.011 |
UPDATE |
Coding requirement |
1. For production files, value must be equal to 'P'2. Value must be in File Status Indicator List (VVL)3. Value must be 1 character4. Mandatory |
1. For production files, value must be equal to "P"2. Value must be in File Status Indicator List (VVL)3. Value must be 1 character4. Mandatory |
| 09/12/2024 |
3.29.0 |
PRV.001.007 |
UPDATE |
Coding requirement |
1. Value must be in State Code List (VVL)2. Value must be 2 characters3. Mandatory4. Value must be the same for all records |
1. Value must be in State Code List (VVL)2. Value must be 2 characters3. Mandatory |
| 09/12/2024 |
3.29.0 |
PRV.001.006 |
UPDATE |
Coding requirement |
1. Value must equal 'PROVIDER'2. Mandatory |
1. Value must equal "PROVIDER"2. Mandatory |
| 09/12/2024 |
3.29.0 |
MCR.007.088 |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
MCR.007.087 |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
MCR.006.079 |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19, 20, 99] |
| 09/12/2024 |
3.29.0 |
MCR.006.078 |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19, 20] |
| 09/12/2024 |
3.29.0 |
MCR.005.070 |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
MCR.005.069 |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
MCR.005.067 |
UPDATE |
Coding requirement |
1. Value must be in Operating Authority List (VVL)2. Value must be 2 characters or less3. Mandatory |
1. Value must be in Operating Authority List (VVL)2. Value must be 2 characters3. Mandatory |
| 09/12/2024 |
3.29.0 |
MCR.004.060 |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
MCR.004.059 |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
MCR.004.058 |
UPDATE |
Coding requirement |
1. Value must be in Managed Care Service Area Name List (VVL)2. If associated Managed Care Service Area (MCR.002.029) is in [ 2, 3, 4, 5, 6 ], then value is mandatory and must be provided3. Value must not contain a pipe or asterisk symbol4. Value must be 30 characters or less5. Conditional6. If associated Managed Care Service Area (MCR.002.029) equals '5' (zipcode), then value must be a 5-digit zipcode7. If associated Managed Care Service Area (MCR.002.029) equals '2' (county code), then value must be a 3-digit number |
1. Value must be in Managed Care Service Area Name List (VVL)2. If associated Managed Care Service Area (MCR.002.029) is in [2,3,4,5,6], then value is mandatory and must be provided3. Value must not contain a pipe or asterisk symbol4. Value must be 30 characters or less5. Conditional6. If associated Managed Care Service Area (MCR.002.029) equals "5" (zipcode), then value must be a 5-digit zipcode7. If associated Managed Care Service Area (MCR.002.029) equals "2" (county code), then value must be a 3-digit number |
| 09/12/2024 |
3.29.0 |
MCR.003.050 |
UPDATE |
Coding requirement |
1. Must contain the '@' symbol2. May contain uppercase and lowercase Latin letters A to Z and a to z3. May contain digits 0-94. Must contain a dot '.' that is not the first or last character and provided that it does not appear consecutively5. Value must be 60 characters or less6. Situational |
1. Must contain the '@' symbol2. May contain uppercase and lowercase Latin letters A to Z and a to z3. May contain digits 0-94. Must contain a dot "." that is not the first or last character and provided that it does not appear consecutively5. Value must be 60 characters or less6. Situational |
| 09/12/2024 |
3.29.0 |
MCR.003.044 |
UPDATE |
Coding requirement |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 (CE) or Address Line 2 (CE) value(s)3. If Address Line 2 is not populated, then value should not be populated4. Value must not contain a pipe or asterisk symbols5. Conditional |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 or Address Line 2 value(s)3. If Address Line 2 is not populated, then value should not be populated4. Value must not contain a pipe or asterisk symbols5. Conditional |
| 09/12/2024 |
3.29.0 |
MCR.003.040 |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
MCR.003.039 |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
MCR.003.038 |
UPDATE |
Coding requirement |
1. Value must not contain a pipe symbol2. Each managed care entity's locations must have a unique identifier3. Value must be populated if associated Managed Care Address Type (MCR.003.041) equals 3 (Managed care entity's service location address)4. Value must be 15 characters or less5. Mandatory |
1. Value must not contain a pipe symbol2. Each managed care entity's locations must have a unique identifier3. Value must be populated if associated Managed Care Address Type (MCR.003.041) equals "3" (Managed care entity's service location address)4. Value must be 15 characters or less5. Mandatory |
| 09/12/2024 |
3.29.0 |
MCR.002.031 |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
MCR.002.030 |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
MCR.002.029 |
UPDATE |
Coding requirement |
1. Value must be in Managed Care Service Area List (VVL)2. Value must be 1 character3. Mandatory4. When value equals '2', the associated Managed Care Service Area Name (MCR.004.058) value must be a valid US County Code |
1. Value must be in Managed Care Service Area List (VVL)2. Value must be 1 character3. Mandatory4. When value equals "2", the associated Managed Care Service Area Name (MCR.004.058) value must be a valid US County Code |
| 09/12/2024 |
3.29.0 |
MCR.002.020 |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20']6. Mandatory7. Value must occur before Managed Care Contract End Date (MCR.002.021) |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20]6. Mandatory7. Value must occur before Managed Care Contract End Date (MCR.002.021) |
| 09/12/2024 |
3.29.0 |
MCR.001.011 |
UPDATE |
Coding requirement |
1. For production files, value must be equal to 'P'2. Value must be in File Status Indicator List (VVL)3. Value must be 1 character4. Mandatory |
1. For production files, value must be equal to "P"2. Value must be in File Status Indicator List (VVL)3. Value must be 1 character4. Mandatory |
| 09/12/2024 |
3.29.0 |
MCR.001.007 |
UPDATE |
Coding requirement |
1. Value must be in State Code List (VVL)2. Value must be 2 characters3. Mandatory4. Value must be the same for all records |
1. Value must be in State Code List (VVL)2. Value must be 2 characters3. Mandatory |
| 09/12/2024 |
3.29.0 |
MCR.001.006 |
UPDATE |
Coding requirement |
1. Value must equal 'MNGDCARE'2. Mandatory |
1. Value must equal "MNGDCARE"2. Mandatory |
| 09/12/2024 |
3.29.0 |
ELG.022.266 |
UPDATE |
Definition |
A code to identify the reason for changing the MSIS Identification Number of a beneficiary and only required for Eligibile Identifier Type = '2-Old MSIS Identification Number'. For example, If MSIS Identification Number of a beneficiary is being changed due to 'Merge with other MSIS ID'
or 'Unmerge'. |
A code to identify the reason for changing the MSIS Identification Number of a beneficiary and only required for Eligibile Identifier Type = "2-Old MSIS Identification Number". For example, If MSIS Identification Number of a beneficiary is being changed due to "Merge with other MSIS ID"
or "Unmerge". |
| 09/12/2024 |
3.29.0 |
ELG.022.266 |
UPDATE |
Coding requirement |
1. Value must be in Reason for Change List (VVL)2. Value must be 10 characters or less3. Conditional4. (Old MSIS Identification Number) value must be populated when Eligible Identifier Type (ELG.022.261) equals '2' |
1. Value must be in Reason for Change List (VVL)2. Value must be 10 characters or less3. Conditional4. (Old MSIS Identification Number) value must be populated when Eligible Identifier Type (ELG.022.261) equals "2" |
| 09/12/2024 |
3.29.0 |
ELG.022.265 |
UPDATE |
Definition |
A data element to capture the various identifiers assigned to Medicaid and CHIP beneficiary by various entities. The specific type of identifier is shown in the corresponding value in the Eligible Identifier Type data element. States should provide all Old MSIS Identification Number with Eligible Identifier Type = 2 to T-MSIS in case the state changes the MSIS Identification Number of a beneficiary. The state should submit updates to T-MSIS whenever an identifier is retired or issued. States should provide Old MSIS Identification Number with Reason for Change = 'MERGE' to T-MSIS if the state was reporting multiple MSIS Identification Numbers for a single beneficiary and merges them under a single MSIS Identification Number. States should provide Old MSIS Identification Number with Reason for Change = 'UNMERGE' to T-MSIS if the state unmerges a beneficiary from another beneficiary. For example, if a newborn child is originally reported with the mother's MSIS Identification Number and is then assigned a different MSIS Identification Number. States should provide Old MSIS Identification Number with Reason for Change = 'LSE' to T-MSIS if the state assigns a new MSIS Identification Number to any beneficiaries during large system enhancement in state MMIS. States should provide Old MSIS Identification Number with Reason for Change = 'TCAM' to T-MSIS if the Medicaid and Separate CHIP programs use different MSIS Identifier Number schemas and beneficiaries are transferred from CHIP to Medicaid or from Medicaid to CHIP and a new MSIS Identification Number is issued. |
A data element to capture the various identifiers assigned to Medicaid and CHIP beneficiary by various entities. The specific type of identifier is shown in the corresponding value in the Eligible Identifier Type data element. States should provide all Old MSIS Identification Number with Eligible Identifier Type = "2" to T-MSIS in case the state changes the MSIS Identification Number of a beneficiary. The state should submit updates to T-MSIS whenever an identifier is retired or issued. States should provide Old MSIS Identification Number with Reason for Change = "MERGE" to T-MSIS if the state was reporting multiple MSIS Identification Numbers for a single beneficiary and merges them under a single MSIS Identification Number. States should provide Old MSIS Identification Number with Reason for Change = "UNMERGE" to T-MSIS if the state unmerges a beneficiary from another beneficiary. For example, if a newborn child is originally reported with the mother's MSIS Identification Number and is then assigned a different MSIS Identification Number. States should provide Old MSIS Identification Number with Reason for Change = "LSE" to T-MSIS if the state assigns a new MSIS Identification Number to any beneficiaries during large system enhancement in state MMIS. States should provide Old MSIS Identification Number with Reason for Change = "TCAM" to T-MSIS if the Medicaid and Separate CHIP programs use different MSIS Identifier Number schemas and beneficiaries are transferred from CHIP to Medicaid or from Medicaid to CHIP and a new MSIS Identification Number is issued. |
| 09/12/2024 |
3.29.0 |
ELG.022.264 |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
ELG.022.263 |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
ELG.022.262 |
UPDATE |
Coding requirement |
Value must be 18 characters or less |
1. Value must be 18 characters or less |
| 09/12/2024 |
3.29.0 |
ELG.022.260 |
UPDATE |
Definition |
A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
| 09/12/2024 |
3.29.0 |
ELG.021.254 |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
ELG.021.253 |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
ELG.021.252 |
UPDATE |
Coding requirement |
1. Value must be in Enrollment Type List (VVL)2. Value must be 1 character3. If value equals 1, then associated CHIP Code (ELG.003.054) value must be in [1, 2]4. If value equals 2, then associated CHIP Code (ELG.003.054) value must be "3"5. A person enrolled in Medicaid/CHIP must have a primary eligibility group classification for any given day of enrollment. (There may or may not be a secondary eligibility group classification for that same day.)6. Mandatory |
1. Value must be in Enrollment Type List (VVL)2. Value must be 1 character3. If value equals "1", then associated CHIP Code (ELG.003.054) value must be in [1,2]4. If value equals "2", then associated CHIP Code (ELG.003.054) value must be "3"5. A person enrolled in Medicaid/CHIP must have a primary eligibility group classification for any given day of enrollment. (There may or may not be a secondary eligibility group classification for that same day).6. Mandatory |
| 09/12/2024 |
3.29.0 |
ELG.020.244 |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
ELG.020.243 |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
ELG.018.235 |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
ELG.018.234 |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
ELG.018.233 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
ELG.017.226 |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
ELG.017.225 |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
ELG.016.217 |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
ELG.016.216 |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
ELG.016.215 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in American Indian Alaskan Native Indicator List (VVL)4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in American Indian Alaskan Native Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
ELG.016.214 |
UPDATE |
Coding requirement |
1. If associated Race (ELG.016.213) value is in [ "010", "015" ], then value must be populated.2. Value must not contain a pipe or asterisk symbol3. Value must be 25 characters or less4. Conditional |
1. If associated Race (ELG.016.213) value is in [010,015,018], then value must be populated.2. Value must not contain a pipe or asterisk symbol3. Value must be 25 characters or less4. Conditional |
| 09/12/2024 |
3.29.0 |
ELG.015.271 |
UPDATE |
Coding requirement |
1. Value must be 25 characters or less2. If associated Ethnicity Code (ELG.015.204) is in ["4"], then value must be populated. 3. Conditional |
1. Value must be 25 characters or less2. If associated Ethnicity Code (ELG.015.204) is in ["4"], then value must be populated.3. Conditional |
| 09/12/2024 |
3.29.0 |
ELG.015.206 |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
ELG.015.205 |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
ELG.015.204 |
UPDATE |
Definition |
A code indicating that the individual's ethnicity is Hispanic, Latino/a, or Spanish ethnicity of a Medicaid/CHIP enrolled individual..
Ethnicity Code clarifications:
If state has beneficiaries coded in their database as "Hispanic" or "Latino," then code them in T-MSIS as "Hispanic or Latino Unknown" (valid value "5"). DO NOT USE "Another Hispanic, Latino, or Spanish Origin," "Ethnicity Unknown" or "Ethnicity Unspecified."
NOTE 1: The "Ethnicity Unspecified" category in T-MSIS (valid value "6") should be used with an individual who explicitly did not provide information or refused to answer a question. |
A code indicating that the individual's ethnicity is Hispanic, Latino/a, or Spanish ethnicity of a Medicaid/CHIP enrolled individual.
Ethnicity Code clarifications:
If state has beneficiaries coded in their database as "Hispanic" or "Latino," then code them in T-MSIS as "Hispanic or Latino Unknown" (valid value "5"). DO NOT USE "Another Hispanic, Latino, or Spanish Origin," "Ethnicity Unknown" or "Ethnicity Unspecified."
NOTE 1: The "Ethnicity Unspecified" category in T-MSIS (valid value "6") should be used with an individual who explicitly did not provide information or refused to answer a question. |
| 09/12/2024 |
3.29.0 |
ELG.014.197 |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
ELG.014.196 |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
ELG.013.185 |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
ELG.013.184 |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
ELG.012.175 |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
ELG.012.174 |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
ELG.012.172 |
UPDATE |
Coding requirement |
1. Value must have a corresponding value in Waiver Type (ELG.012.173)2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by a version number [0-9] in the 12th position5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Mandatory |
1. Value must have a corresponding value in Waiver Type (ELG.012.173)2. Value must be 20 characters or less3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be "01" or in [21-30]4. (1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20,32,33]6. Mandatory |
| 09/12/2024 |
3.29.0 |
ELG.011.165 |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
ELG.011.164 |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
ELG.011.163 |
UPDATE |
Coding requirement |
1. Value must be in State Plan Option Type List (VVL)2. If associated Eligibility Group (ELG.005.087) value is in [ "72", "73", "74", "75" ], and Restricted Benefits Code (ELG.DE.097) is "1" or "7", then value must be "06"3. Value must be 2 characters4. Mandatory5. Value must equal '02' when Program Type (CIP.002.129) equals '13'6. Value must equal '02' when Program Type (COT.002.065) equals '13' |
1. Value must be in State Plan Option Type List (VVL)2. If associated Eligibility Group (ELG.005.087) value is in [ "72", "73", "74", "75" ], and Restricted Benefits Code (ELG.DE.097) is "1" or "7", then value must be "06"3. Value must be 2 characters4. Mandatory5. Value must equal "02" when Program Type (CIP.002.129) equals "13"6. Value must equal "02" when Program Type (COT.002.065) equals "13" |
| 09/12/2024 |
3.29.0 |
ELG.011.159 |
UPDATE |
Coding requirement |
1. Mandatory2. Value must be 8 characters3. Value must be in Record ID List (VVL)4. Value must equal "ELG00011" |
1. Mandatory3. Value must be in Record ID List (VVL)3. Value must be in Record ID List (VVL)4. Value must equal "ELG00011" |
| 09/12/2024 |
3.29.0 |
ELG.010.156 |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
ELG.010.155 |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
ELG.010.153 |
UPDATE |
Coding requirement |
1. Value must be in MFP Reason Participation Ended List (VVL)2. Value must be 2 characters3. Conditional4. Value must not be populated when Enrollment End Date equals '9999-12-31'5. Value must be populated when Enrollment End Date does not equal '9999-12-31' |
1. Value must be in MFP Reason Participation Ended List (VVL)2. Value must be 2 characters3. Conditional4. Value must not be populated when Enrollment End Date equals "9999-12-31"5. Value must be populated when Enrollment End Date does not equal "9999-12-31" |
| 09/12/2024 |
3.29.0 |
ELG.009.270 |
UPDATE |
Coding requirement |
1. Value must be 3 characters2. Conditional3. Must be a 3 digit value from the Type-of-Service (VVL) |
1. Value must be 3 characters2. Conditional3. Value must be in Type of Service List (VVL) |
| 09/12/2024 |
3.29.0 |
ELG.009.143 |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
ELG.009.142 |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
ELG.008.133 |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
ELG.008.132 |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
ELG.007.122 |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
ELG.007.121 |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in[18,19,20] |
| 09/12/2024 |
3.29.0 |
ELG.006.110 |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
ELG.006.109 |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
ELG.005.100 |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
ELG.005.099 |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
ELG.005.097 |
UPDATE |
Coding requirement |
1. Value must be in Restricted Benefits Code List (VVL)2. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "05", then Eligibility Group (ELG.005.087) must be "24"3. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "06", then Eligibility Group (ELG.005.087) must be "26"4. (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "02", then Eligibility Group (ELG.005.087) must be "23"5. (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "04", then Eligibility Group (ELG.005.087) must be "25"6. (Restricted Benefits) if value is "3", then Dual Eligible Code (ELG.005.085) cannot be "00"7. Mandatory8. If value is populated, then Eligibility Group (ELG.005.087) must be populated.9. If value is "6" then Eligibility Group(ELG.DE.087) must be in ("35", "70")10. If value is "1" or "7" then Eligibility Group (EGL.DE.087) must be in ("72", "73", "74", "75") and State Plan Option Type (ELG.DE.163) must equal to "06"11. (Restricted Pregnancy-Related) if value is "4", then associated Sex (ELG.002.023) value must be "F"12. (Non-Citizen) if value is "2", then associated Citizenship Indicator (ELG.003.040) value must not be equal to "1"13. If value is "D", there must be a corresponding MFP enrollment segment (ELG00010) with Effective and End dates that are within the timespan of this segment14. Value must be 1 character15. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "01", then Eligibility Group (ELG.005.087) must be "23"16. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "03", then Eligibility Group (ELG.005.087) must be "25"17. (Restricted Benefits) if value is "G", then Dual Eligible Code (ELG.005.085) must be in (‘01’, ‘03', ‘06’) |
1. Value must be in Restricted Benefits Code List (VVL)2. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "05", then Eligibility Group (ELG.005.087) must be "24"3. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "06", then Eligibility Group (ELG.005.087) must be "26"4. (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "02", then Eligibility Group (ELG.005.087) must be "23"5. (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "04", then Eligibility Group (ELG.005.087) must be "25"6. (Restricted Benefits) if value is "3", then Dual Eligible Code (ELG.005.085) cannot be "00"7. Mandatory8. If value is populated, then Eligibility Group (ELG.005.087) must be populated9. If value is "6" then Eligibility Group(ELG.DE.087) must be in [35,70]10. If value is "1" or "7" then Eligibility Group (EGL.DE.087) must be in [72,73,74,75] and State Plan Option Type (ELG.DE.163) must equal "06"11. (Restricted Pregnancy-Related) if value is "4", then associated Sex (ELG.002.023) value must be "F"12. (Non-Citizen) if value is "2", then associated Citizenship Indicator (ELG.003.040) value must not be equal to "1"13. If value is "D", there must be a corresponding MFP enrollment segment (ELG00010) with Effective and End dates that are within the timespan of this segment14. Value must be 1 character15. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "01", then Eligibility Group (ELG.005.087) must be "23"16. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "03", then Eligibility Group (ELG.005.087) must be "25"17. (Restricted Benefits) if value is "G", then Dual Eligible Code (ELG.005.085) must be in [01,03,06] |
| 09/12/2024 |
3.29.0 |
ELG.005.095 |
UPDATE |
Definition |
The reason for a complete loss/termination in an individual's eligibility for Medicaid and CHIP. The end date of the segment in which the value is reported must represent the date that the complete loss/termination of Medicaid and CHIP eligibility occurred. The reason for the termination represents the reason that the segment in which it was reported was closed. If for a single termination in eligibility for a single individual there are multiple distinct co-occurring values in the state's system explaining the reason for the termination, and if one of the multiple co-occurring values maps to T-MSIS ELIGIBILITY-CHANGE-REASON value '21' (Other) or '22' (Unknown), then the state should not report the co-occurring value '21' and/or '22' to T-MSIS. If there are multiple co-occurring distinct values between '01' and '19', then the state should choose whichever is first in the state's system. Of the values that could logically co-occur in the range of '01' through '19', CMS does not currently have a preference for any one value over another. Do not populate if at the time someone loses Medicaid eligibility they become eligible for and enrolled in CHIP. Also do not populate if at the time someone loses CHIP eligibility they become eligible for and enrolled in Medicaid. |
The reason for a complete loss/termination in an individual's eligibility for Medicaid and CHIP. The end date of the segment in which the value is reported must represent the date that the complete loss/termination of Medicaid and CHIP eligibility occurred. The reason for the termination represents the reason that the segment in which it was reported was closed. If for a single termination in eligibility for a single individual there are multiple distinct co-occurring values in the state's system explaining the reason for the termination, and if one of the multiple co-occurring values maps to T-MSIS ELIGIBILITY-CHANGE-REASON value "21" (Other) or "22" (Unknown), then the state should not report the co-occurring value "21" and/or "22" to T-MSIS. If there are multiple co-occurring distinct values between "01" and "19", then the state should choose whichever is first in the state's system. Of the values that could logically co-occur in the range of "01" through "19", CMS does not currently have a preference for any one value over another. Do not populate if at the time someone loses Medicaid eligibility they become eligible for and enrolled in CHIP. Also do not populate if at the time someone loses CHIP eligibility they become eligible for and enrolled in Medicaid. |
| 09/12/2024 |
3.29.0 |
ELG.005.094 |
UPDATE |
Coding requirement |
1. Value must be in Conception to Birth Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If the value is equal to "1", then the Eligibility Group (ELG.005.087) must equal "64"5. If the value is equal to "1", then any associated claims must indicate the Program Type = '14' (State Plan CHIP)6. If the value is equal to "1", then CHIP Code (ELG.003.054) must equal "3" (Individual was not Medicaid Expansion CHIP eligible, but was included in a separate title XXI CHIP Program)7. Conditional |
1. Value must be in Conception to Birth Indicator List (VVL)2. Value must be 1 character3. Value must be in [0,1] or not populated4. If the value is equal to "1", then the Eligibility Group (ELG.005.087) must equal "64"5. If the value is equal to "1", then any associated claims must indicate the Program Type = "14" (State Plan CHIP)6. If the value is equal to "1", then CHIP Code (ELG.003.054) must equal "3" (Individual was not Medicaid Expansion CHIP eligible, but was included in a separate title XXI CHIP Program)7. Conditional |
| 09/12/2024 |
3.29.0 |
ELG.005.092 |
UPDATE |
Coding requirement |
1. Value must be in SSI Status List (VVL)2. Value must be 3 characters3. Conditional4. When value is '001' or '002', then SSI Indicator must be '1'5. When value is '000' or '003' or not populate, then SSI Indicator must be '0' |
1. Value must be in SSI Status List (VVL)2. Value must be 3 characters3. Conditional4. When value is "001" or "002", then SSI Indicator must be "1"5. When value is "000" or "003" or not populate, then SSI Indicator must be "0" |
| 09/12/2024 |
3.29.0 |
ELG.005.090 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in SSI Indicator List (VVL)4. Value must be 1 character5. Conditional6. Value must equal '0' when SSI status (ELG.005.092) equals '000' or '003' or is not populated7. Value must equal '1' when SSI status (ELG.005.092) equals '001' or '002' |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in SSI Indicator List (VVL)4. Value must be 1 character5. Conditional6. Value must equal "0" when SSI status (ELG.005.092) equals "000" or "003" or is not populated7. Value must equal "1" when SSI status (ELG.005.092) equals "001" or "002" |
| 09/12/2024 |
3.29.0 |
ELG.005.087 |
UPDATE |
Coding requirement |
Value must be in Eligibility Group List (VVL)2. If value is "26", then Dual Eligible Code value must be "06"3. Conditional4. Value is mandatory and must be provided when associated Eligibility Determinant Effective Date value is on or after 1 January, 2014.5. If value is in [ "72", "73", "74", "75" ], then associated Restricted Benefits Code value must equal "1" or "7" and State Plan Option Type must equal "06"6. If associated CHIP Code value is "2", then value must be in [ "07", 31", "61" ]7. If associated CHIP Code value is "3", then value must be in [ "61", "62", "63", "64", "65", "66", "67", "68" ]8. Value must be 2 characters9. If value is "23", then Dual Eligible Code value must be in ["01", "02"]10. If value is "25", then Dual Eligible Code value must be in ["03", "04"]11. If value is "24", then Dual Eligible Code value must be "05"12. If value is "26", then Dual Eligible Code value must be "06" |
1. Value must be in Eligibility Group List (VVL)2. If value is "26", then Dual Eligible Code value must be "06"3. Conditional4. Value is mandatory and must be provided when associated Eligibility Determinant Effective Date value is on or after 1 January, 2014.5. If value is in [72,73,74,75], then associated Restricted Benefits Code value must equal "1" or "7" and State Plan Option Type must equal "06"6. If associated CHIP Code value is "2", then value must be in [07,31,61]7. If associated CHIP Code value is 3,then value must be in [61,62,63,64,65,66,67,68]8. Value must be 2 characters9. If value is "23", then Dual Eligible Code value must be in [01,02]10. If value is "25", then Dual Eligible Code value must be in [03,04]11. If value is "24", then Dual Eligible Code value must be "05"12. If value is "26", then Dual Eligible Code value must be "06" |
| 09/12/2024 |
3.29.0 |
ELG.005.086 |
UPDATE |
Definition |
A flag indicating the eligibility record is the primary eligibility in cases where there are multiple eligibility records submitted with overlapping or concurrent eligibility determinant effective and end dates. It is expected that an enrollee's eligibility group assignment (ELG087 - ELIGIBILITY-GROUP) will change over time as his/her situation changes. Whenever the eligibility group assignment changes (i.e., ELG087 has a different value), a separate ELIGIBILITY-DETERMINANTS record segment must be created. In such situations, there would be multiple ELIGIBILITY-DETERMINANTS record segments, each covering a different effective time span. In such situations, the value in ELG087 would be the primary eligibility group for the effective date span of its respective ELIGIBILITY-DETERMINANTS record segment, and the PRIMARY-ELIGIBILITY-GROUP-IND data element on each of these segments would be set to '1' (YES). Should a situation arise where a Medicaid/CHIP enrollee has been assigned both a primary and one or more secondary eligibility groups, there would be two or more ELIGIBILITY-DETERMINANTS record segments with overlapping effective time spans - one segment containing the primary eligibility group and the other(s) for the secondary eligibility group(s). To differentiate the primary eligibility group from the secondary group(s), only one segment should be assigned as the primary group using PRIMARY-ELIGIBILITY-GROUP-IND = 1; the others should be assigned PRIMARY-ELIGIBILITY-GROUP-IND = 0. |
A flag indicating the eligibility record is the primary eligibility in cases where there are multiple eligibility records submitted with overlapping or concurrent eligibility determinant effective and end dates. It is expected that an enrollee's eligibility group assignment (ELG087 - ELIGIBILITY-GROUP) will change over time as his/her situation changes. Whenever the eligibility group assignment changes (i.e., ELG087 has a different value), a separate ELIGIBILITY-DETERMINANTS record segment must be created. In such situations, there would be multiple ELIGIBILITY-DETERMINANTS record segments, each covering a different effective time span. In such situations, the value in ELG087 would be the primary eligibility group for the effective date span of its respective ELIGIBILITY-DETERMINANTS record segment, and the PRIMARY-ELIGIBILITY-GROUP-IND data element on each of these segments would be set to "1"(YES). Should a situation arise where a Medicaid/CHIP enrollee has been assigned both a primary and one or more secondary eligibility groups, there would be two or more ELIGIBILITY-DETERMINANTS record segments with overlapping effective time spans - one segment containing the primary eligibility group and the other(s) for the secondary eligibility group(s). To differentiate the primary eligibility group from the secondary group(s), only one segment should be assigned as the primary group using PRIMARY-ELIGIBILITY-GROUP-IND = "1"; the others should be assigned PRIMARY-ELIGIBILITY-GROUP-IND = "0". |
| 09/12/2024 |
3.29.0 |
ELG.005.086 |
UPDATE |
Coding requirement |
1. Value must be in Primary Eligibility Group Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1]4. Mandatory |
1. Value must be in Primary Eligibility Group Indicator List (VVL)2. Value must be 1 character3. Value must be in [0,1]4. Mandatory |
| 09/12/2024 |
3.29.0 |
ELG.005.085 |
UPDATE |
Coding requirement |
1. Value must be in Dual Eligible Code List (VVL)2. If value is "05", then Eligibility Group (ELG.005.087) must be "24"3. If value is "06", then Eligibility Group (ELG.005.087) must be "26"4. If Dual Eligible Code (ELG.005.085) is "01", "02", "03", 04", 05", "06", "08", "09", or "10", then Primary Eligibility Group Indicator (ELG.005.086) must be "1" (Yes)5. Mandatory6. A partial dual eligible (values="01', "03", "05" or "06") then Restricted Benefits Code (ELG.005.097) must be "3"7. (Not Dual Eligible) if value = "00", then associated Medicare Beneficiary Identifier (ELG.003.051) value must not be populated.8. Value must be 2 characters9. If value is in ["08", "10"] then Restricted Benefits Code (ELG.005.097) must be "1"10. If value is "09", then Eligibility Group (ELG.005.087) and Restricted Benefits Code (ELG.005.097) must not be populated11. If value equals "10", then CHIP Code (ELG.003.054) must be "03" (S-CHIP) and Medicare Beneficiary Identifier (ELG.003.051) must be populated12. If value is "01", then Eligibility Group (ELG.005.087) must be "23"13. If value is "03", then Eligibility Group (ELG.005.087) must be "25" |
1. Value must be in Dual Eligible Code List (VVL)2. If value is "05", then Eligibility Group (ELG.005.087) must be "24"3. If value is "06", then Eligibility Group (ELG.005.087) must be "26"4. If Dual Eligible Code (ELG.005.085) is in [01,02,03,04,05,06,08,09,10], then Primary Eligibility Group Indicator (ELG.005.086) must be "1" (Yes)5. Mandatory6. A partial dual eligible (values 01,03,05,06) must have a Restricted Benefits Code (ELG.005.097) equal to "3"7. (Not Dual Eligible) if value = "00", then associated Medicare Beneficiary Identifier (ELG.003.051) value must not be populated.8. Value must be 2 characters9. If value is in ["08", "10"] then Restricted Benefits Code (ELG.005.097) must be "1"10. If value is "09", then Eligibility Group (ELG.005.087) and Restricted Benefits Code (ELG.005.097) must not be populated11. If value equals "10", then CHIP Code (ELG.003.054) must be "03" (S-CHIP) and Medicare Beneficiary Identifier (ELG.003.051) must be populated12. If value is "01", then Eligibility Group (ELG.005.087) must be "23"13. If value is "03", then Eligibility Group (ELG.005.087) must be "25" |
| 09/12/2024 |
3.29.0 |
ELG.004.076 |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
ELG.004.075 |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
ELG.004.073 |
UPDATE |
Coding requirement |
1. Value must be 10-digit number2. Conditional3. If Eligible Address Type (ELG.004.065) = ''01', then value is mandatory and must be provided |
1. Value must be 10-digit number2. Conditional3. If Eligible Address Type (ELG.004.065) equals "01", then value is mandatory and must be provided |
| 09/12/2024 |
3.29.0 |
ELG.004.065 |
UPDATE |
Coding requirement |
1. Value must be in Eligible Address Type List (VVL)2. Value must be 2 characters3. Mandatory |
1. Value must be in Eligible Address Type List (VVL)2. Value must be 2 characters3. Mandatory4. When Address Type equals "01" (Primary), Eligible State (ELG.004.070) must equal Submitting State (ELG.001.007) |
| 09/12/2024 |
3.29.0 |
ELG.003.269 |
UPDATE |
Definition |
This data element provides the beneficiary's or their household's income as a percentage of the federal poverty level. Used to assign the beneficiary to the eligibility group that covered their Medicaid or CHIP benefits. If the beneficiary's income was assessed using multiple methodologies (MAGI and Non-MAGI), report the income that applies to their primary eligibility group.A beneficiary’s income is applicable unless it is not required by the eligibility group for which they were determined eligible. For example, the eligibility groups for children with adoption assistance, foster care, or guardianship care under title IV-E and optional eligibility for individuals needing treatment for breast or cervical cancer do not have a Medicaid income test. Additionally, for individuals receiving SSI, states with section 1634 agreements with the Social Security Administration (SSA) and states that use SSI financial methodologies for Medicaid determinations do not conduct separate Medicaid financial eligibility for this group. |
This data element provides the beneficiary's or their household's income as a percentage of the federal poverty level. Used to assign the beneficiary to the eligibility group that covered their Medicaid or CHIP benefits. If the beneficiary's income was assessed using multiple methodologies (MAGI and Non-MAGI), report the income that applies to their primary eligibility group.
A beneficiary’s income is applicable unless it is not required by the eligibility group for which they were determined eligible. For example, the eligibility groups for children with adoption assistance, foster care, or guardianship care under title IV-E and optional eligibility for individuals needing treatment for breast or cervical cancer do not have a Medicaid income test. Additionally, for individuals receiving SSI, states with section 1634 agreements with the Social Security Administration (SSA) and states that use SSI financial methodologies for Medicaid determinations do not conduct separate Medicaid financial eligibility for this group. |
| 09/12/2024 |
3.29.0 |
ELG.003.058 |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
ELG.003.057 |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
ELG.003.054 |
UPDATE |
Coding requirement |
1. Value must be in CHIP Code List (VVL)2. If value is in [ 2, 3 ], then associated Eligibility Group (ELG.005.087) value must be in [ "07", "31", "61", 62", "63", "64", "65", "66", "67", or "68" ]3. If value is "1", then associated Eligibility Group (ELG.005.087) value must not be in [ "61", 62", "63", "64", "65", "66", "67", or "68" ]4. Value must be 1 character5. Mandatory |
1. Value must be in CHIP Code List (VVL)2. If value is in [ 2, 3 ], then associated Eligibility Group (ELG.005.087) value must be in [07,31,61,62,63,64,65,66,67,68 ]3. If value is 1, then associated Eligibility Group (ELG.005.087) value must not be in [61,62,63,64,65,66,67,68]4. Value must be 1 character5. Mandatory |
| 09/12/2024 |
3.29.0 |
ELG.003.051 |
UPDATE |
Coding requirement |
1. Conditional2. Value must be an 11-character string3. Character 1 must be numeric values 1 thru 94. Character 2 must be alphabetic values A thru Z (minus S, L, O, I, B, Z)5. Character 3 must be alphanumeric values 0 thru 9 or A thru Z (minus S, L, O, I, B, Z)6. Character 4 must be numeric values 0 thru 97. Character 5 must be alphabetic values A thru Z (minus S, L, O, I, B, Z)8. Character 6 must be alphanumeric values 0 thru 9 or A thru Z (minus S, L, O, I, B, Z)9. Character 7 must be numeric values 0 thru 910. Character 8 must be alphabetic values A thru Z (minus S, L, O, I, B, Z)11. Character 9 must be alphabetic values A thru Z (minus S, L, O, I, B, Z)12. Character 10 must be numeric values 0 thru 913. Character 11 must be numeric values 0 thru 914. Value must not contain a pipe or asterisk symbols15. When Dual Eligible Code (ELG.005.085) equals '00' and End of Time Period (ELG.001.010) greater than or equal to '2015-11-01', value should not be populated16. (Medicare Enrolled) if associated Dual Eligible Code value (ELG.005.085) is in [ "01", "02", "03", "04", "05", "06", "08", "09", or "10" ], then the value for either HICN or MBI is mandatory and must be provided |
1. Conditional2. Value must be an 11 character string3. Character 1 must be numeric values 1 thru 94. Character 2 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)5. Character 3 must be alphanumeric values 0 thru 9 or A thru Z (minus S,L,O,I,B,Z)6. Character 4 must be numeric values 0 thru 97. Character 5 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)8. Character 6 must be alphanumeric values 0 thru 9 or A thru Z (minus S,L,O,I,B,Z)9. Character 7 must be numeric values 0 thru 910. Character 8 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)11. Character 9 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)12. Character 10 must be numeric values 0 thru 913. Character 11 must be numeric values 0 thru 914. Value must not contain a pipe or asterisk symbols15. When Dual Eligible Code (ELG.005.085) equals "00" and End of Time Period (ELG.001.010) greater than or equal to "2015-11-01", value should not be populated16. (Medicare Enrolled) if associated Dual Eligible Code value (ELG.005.085) is in [ "01", "02", "03", "04", "05", "06", "08", "09", or "10" ], then the value for either HICN or MBI is mandatory and must be provided |
| 09/12/2024 |
3.29.0 |
ELG.003.050 |
UPDATE |
Coding requirement |
1. Conditional2. Value must be 12 characters or less3. Value must not contain a pipe or asterisk symbols4. (Not Dual Eligible) if Dual Eligible Code (ELG.DE.085) value = "00", then value must not be populated.5. (Medicare Enrolled) if associated Dual Eligible Code (ELG.005.085) value is in [ "01", "02", "03", "04", "05", "06", "08", "09", or "10" ], then value for either HICN or MBI is mandatory and must be provided |
1. Conditional2. Value must be 12 characters or less3. Value must not contain a pipe or asterisk symbols4. (Not Dual Eligible) if Dual Eligible Code (ELG.DE.085) value = "00", then value must not be populated.5. (Medicare Enrolled) if associated Dual Eligible Code (ELG.005.085) value is in [01,02,03,04,05,06, 08,09,10], then value for either HICN or MBI is mandatory and must be provided |
| 09/12/2024 |
3.29.0 |
ELG.003.044 |
UPDATE |
Coding requirement |
1. Conditional2. (U.S. Citizen) value should not be populated when Immigration Status (ELG.003.042) equals '8' |
1. Conditional2. (U.S. Citizen) value should not be populated when Immigration Status (ELG.003.042) equals "8" |
| 09/12/2024 |
3.29.0 |
ELG.003.042 |
UPDATE |
Coding requirement |
1. Value must be in Immigration Status List (VVL)2. If associated Citizenship Indicator (ELG.003.040) value is coded as '0', then value must be in [ 1, 2, 3 ]3. If associated Citizenship Indicator (ELG.003.040) value is coded as '1', then value must equal '8'4. Value must be 1 character5. Mandatory |
1. Value must be in Immigration Status List (VVL)2. If associated Citizenship Indicator (ELG.003.040) value is coded as "0", then value must be in [ 1, 2, 3 ]3. If associated Citizenship Indicator (ELG.003.040) value is coded as "1", then value must equal "8"4. Value must be 1 character5. Mandatory |
| 09/12/2024 |
3.29.0 |
ELG.003.041 |
UPDATE |
Coding requirement |
1. Value must be in Citizenship Verification Flag List (VVL)2. Value must be 1 character3. Value must be populated when Citizenship Indicator (ELG.003.040) equals '1' (Yes)4. Conditional |
1. Value must be in Citizenship Verification Flag List (VVL)2. Value must be 1 character3. Value must be populated when Citizenship Indicator (ELG.003.040) equals "1" (Yes)4. Conditional |
| 09/12/2024 |
3.29.0 |
ELG.003.040 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in Citizenship Indicator List (VVL)3. If value is coded as '0', then associated Immigration Status (ELG.003.042) value must be in [ 1, 2, 3 ]4. If value is coded as '1', then associated Immigration Status (ELG.003.042) value must equal '8'5. Mandatory |
1. Value must be 1 character2. Value must be in Citizenship Indicator List (VVL)3. If value is coded as "0", then associated Immigration Status (ELG.003.042) value must be in [ 1, 2, 3 ]4. If value is coded as "1", then associated Immigration Status (ELG.003.042) value must equal "8"5. Mandatory |
| 09/12/2024 |
3.29.0 |
ELG.003.039 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Veteran Indicator List (VVL)4. Conditional5. Value must be populated when Immigration Status (ELG.003.042) is in ['1', '2', '3'] |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Veteran Indicator List (VVL)4. Conditional5. Value must be populated when Immigration Status (ELG.003.042) is in [1,2,3] |
| 09/12/2024 |
3.29.0 |
ELG.003.038 |
UPDATE |
Definition |
A code indicating the federal poverty level range in which the family income falls.If the beneficiary's income was assessed using multiple methodologies (MAGI and Non-MAGI), report the income that applies to their primary eligibility group.A beneficiary’s income is applicable unless it is not required by the eligibility group for which they were determined eligible. For example, the eligibility groups for children with adoption assistance, foster care, or guardianship care under title IV-E and optional eligibility for individuals needing treatment for breast or cervical cancer do not have a Medicaid income test. Additionally, for individuals receiving SSI, states with section 1634 agreements with the Social Security Administration (SSA) and states that use SSI financial methodologies for Medicaid determinations do not conduct separate Medicaid financial eligibility for this group. |
A code indicating the federal poverty level range in which the family income falls.
If the beneficiary's income was assessed using multiple methodologies (MAGI and Non-MAGI), report the income that applies to their primary eligibility group.
A beneficiary’s income is applicable unless it is not required by the eligibility group for which they were determined eligible. For example, the eligibility groups for children with adoption assistance, foster care, or guardianship care under title IV-E and optional eligibility for individuals needing treatment for breast or cervical cancer do not have a Medicaid income test. Additionally, for individuals receiving SSI, states with section 1634 agreements with the Social Security Administration (SSA) and states that use SSI financial methodologies for Medicaid determinations do not conduct separate Medicaid financial eligibility for this group. |
| 09/12/2024 |
3.29.0 |
ELG.003.035 |
UPDATE |
Coding requirement |
1. If associated Marital Status (ELG.003.035) equals '14' (Other), then value is mandatory and must be provided2. Value must be 50 characters or less3. Value must not contain a pipe or asterisk symbol4. Conditional |
1. If associated Marital Status (ELG.003.035) equals "14" (Other), then value is mandatory and must be provided2. Value must be 50 characters or less3. Value must not contain a pipe or asterisk symbol4. Conditional |
| 09/12/2024 |
3.29.0 |
ELG.003.034 |
UPDATE |
Definition |
A code to classify eligible individual's marital/domestic-relationship status. This element should be reported by the state when the information is material to eligibility (i.e., institutionalization).Because there is no specific statutory or regulatory basis for defining marital status codes, they are being defined in a way that is as flexible for states and data users as possible. States can report at whatever level of granularity is available to them in their system and a data user can choose to use them as-is or roll the values up in broader categories depending on whichever approach best meets their needs. CMS periodically reviews the values reported to MARITAL-STATUS-OTHER-EXPLANATION to determine if states are appropriately using it only when there is no existing MARITAL-STATUS value that reflects the state’s marital status description for an individual AND to determine whether it is necessary to add additional T-MSIS MARITAL-STATUS values to reflect commonly used state martial status descriptions for which there is no existing T-MSIS MARITAL-STATUS value. |
A code to classify eligible individual's marital/domestic-relationship status. This element should be reported by the state when the information is material to eligibility (i.e., institutionalization).
Because there is no specific statutory or regulatory basis for defining marital status codes, they are being defined in a way that is as flexible for states and data users as possible. States can report at whatever level of granularity is available to them in their system and a data user can choose to use them as-is or roll the values up in broader categories depending on whichever approach best meets their needs. CMS periodically reviews the values reported to MARITAL-STATUS-OTHER-EXPLANATION to determine if states are appropriately using it only when there is no existing MARITAL-STATUS value that reflects the state’s marital status description for an individual AND to determine whether it is necessary to add additional T-MSIS MARITAL-STATUS values to reflect commonly used state martial status descriptions for which there is no existing T-MSIS MARITAL-STATUS value. |
| 09/12/2024 |
3.29.0 |
ELG.002.027 |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
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. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
ELG.002.026 |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
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. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
ELG.002.024 |
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. Children enrolled in the Separate CHIP prenatal program option should have a date of birth missing or a date of birth equal to the pregnant mother's date of birth4. When Conception to Birth Indicator (ELG.005.094) does not equal '1' and Eligibility Group (ELG.005.087) does not equal '64' value must be less than or equal to associated End of Time Period value5. Value must be less than or equal to associated Date File Created (ELG.001.008) value6. Mandatory7. When Conception to Birth Indicator (ELG.005.094) does not equal '1' and Eligibility Group (ELG.005.087) does not equal '64' value minus Start of Time Period (ELG.001.10) must be less than 125 years |
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. Children enrolled in the Separate CHIP prenatal program option should have a date of birth missing or a date of birth equal to the pregnant mothers date of birth4. When Conception to Birth Indicator (ELG.005.094) does not equal "1" and Eligibility Group (ELG.005.087) does not equal "64" value must be less than or equal to associated End of Time Period value5. Value must be less than or equal to associated Date File Created (ELG.001.008) value6. Mandatory7. When Conception to Birth Indicator (ELG.005.094) does not equal "1" and Eligibility Group (ELG.005.087) does not equal "64" value minus Start of Time Period (ELG.001.10) must be less than 125 years |
| 09/12/2024 |
3.29.0 |
ELG.002.023 |
UPDATE |
Coding requirement |
1. Value must be in Sex List (VVL)2. Value must be 1 character3. (Pregnancy) if value equals "M", then associated Pregnancy Indicator (ELG.003.049) value must not equal '1'4. Mandatory |
1. Value must be in Sex List (VVL)2. Value must be 1 character3. (Pregnancy) if value equals "M", then associated Pregnancy Indicator (ELG.003.049) value must not equal "1"4. Mandatory |
| 09/12/2024 |
3.29.0 |
ELG.001.011 |
UPDATE |
Coding requirement |
1. For production files, value must be equal to 'P'2. Value must be in File Status Indicator List (VVL)3. Value must be 1 character4. Mandatory |
1. For production files, value must be equal to "P"2. Value must be in File Status Indicator List (VVL)3. Value must be 1 character4. Mandatory |
| 09/12/2024 |
3.29.0 |
ELG.001.006 |
UPDATE |
Coding requirement |
1. Value must equal 'ELIGIBLE'2. Mandatory |
1. Value must equal "ELIGIBLE"2. Mandatory |
| 09/12/2024 |
3.29.0 |
CRX.003.172 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1]3. Mandatory |
1. Value must be 1 character2. Value must be in [0,1]3. Mandatory |
| 09/12/2024 |
3.29.0 |
CRX.003.171 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.003.170 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.003.169 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.003.168 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.003.167 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.003.152 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.003.151 |
UPDATE |
Coding requirement |
1. Value must be in XXI MBESCBES Category of Service List (VVL)2. Conditional3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is '02', then a valid value is mandatory and must be reported4. If XIX MBESCBES Category of Service is populated then value must not be populated5. Value must be 3 characters or less |
1. Value must be in XXI MBESCBES Category of Service List (VVL)2. Conditional3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is "02", then a valid value is mandatory and must be reported4. If XIX MBESCBES Category of Service is populated then value must not be populated5. Value must be 3 characters or less |
| 09/12/2024 |
3.29.0 |
CRX.003.150 |
UPDATE |
Coding requirement |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is '01', then a valid value is mandatory and must be reported5. If value is in ['14', '35', '42' or '44'], then Sex (ELG.002.023) must not equals 'M'6. If XXI MBESCBES Category of Service is populated then must not be populated |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is "01", then a valid value is mandatory and must be reported5. If value is in [14,35,42,44], then Sex (ELG.002.023) must not equals "M"6. If XXI MBESCBES Category of Service is populated then must not be populated |
| 09/12/2024 |
3.29.0 |
CRX.003.149 |
UPDATE |
Coding requirement |
1. Value must be in CMS 64 Category for Federal Reimbursement List (VVL)2. Value must be 2 characters3. (Federal Funding under Title XXI) if value equals '02', then the eligible's CHIP Code (ELG.003.054) must be in ['2', '3']4. (Federal Funding under Title XIX) if value equals '01' then the eligible's CHIP Code (ELG.003.054) must be '1'5. Conditional6. If Type of Claim is in ['1','2','5','A','B','E','U','V','Y'] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported.7. If Type of Claim is in ['4','D'] and the Service Tracking Payment Amount on the relevant record is populated, then value must be reported. |
1. Value must be in CMS 64 Category for Federal Reimbursement List (VVL)2. Value must be 2 characters3. (Federal Funding under Title XXI) if value equals "02", then the eligibles CHIP Code (ELG.003.054) must be in [2, 3]4. (Federal Funding under Title XIX) if value equals "01" then the eligible's CHIP Code (ELG.003.054) must be "1"5. Conditional6. If Type of Claim is in [1,2,5,A,B,E,U,V,Y] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported.7. If Type of Claim is in [4,D] and the Service Tracking Payment Amount on the relevant record is populated, then value must be reported. |
| 09/12/2024 |
3.29.0 |
CRX.003.147 |
UPDATE |
Coding requirement |
Not Applicable |
|
| 09/12/2024 |
3.29.0 |
CRX.003.144 |
UPDATE |
Coding requirement |
1. Value must be numeric2. Value may include up to 7 digits to the left of the decimal point, and 3 digits to the right, e.g. 1234567.8903. Value must be populated when Compound Drug Indicator (CRX.002.086) equals 14. Conditional |
1. Value must be numeric2. Value may include up to 7 digits to the left of the decimal point, and 3 digits to the right, e.g. 1234567.8903. Value must be populated when Compound Drug Indicator (CRX.002.086) equals "1"4. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.003.143 |
UPDATE |
Definition |
A code indicating the conflict, intervention and outcome of a prescription presented for fulfillment. The T-MSIS Drug Utilization Code data element is composite field comprised of three distinct NCPDP data elements: "Reason for Service Code" (439-E4); "Professional Service Code" (440-E5); and "Result of Service Code" (441-E6). All 3 of these NCPDP fields are situationally required and independent of one another. Pharmacists may report none, one, two or all three. NCPDP situational rules call for one or more of these values in situations where the field(s) could result in different coverage, pricing, patient financial responsibility, drug utilization review outcome, or if the information affects payment for, or documentation of, professional pharmacy service. The NCPDP "Reasons of Service Code" (bytes 1 & 2 of the T-MSIS DRUG-UTILIZATION-CODE) explains whether the pharmacist filled the prescription, filled part of the prescription, etc. The NCPDP "Professional Service Code" (bytes 3 & 4 of the T-MSIS Drug Utilization Code) describes what the pharmacist did for the patient. The NCPDP "Result of Service Code" (bytes 5 & 6 of the T-MSIS Drug Utilization Code) describes the action the pharmacist took in response to a conflict or the result of a pharmacist's professional service. Because the T-MSIS Drug Utilization Code data element is a composite field, it is necessary for the state to populate all six bytes if any of the three NCPDP fields has a value. In such situations, use 'spaces' as placeholders for not applicable codes. |
A code indicating the conflict, intervention and outcome of a prescription presented for fulfillment. The T-MSIS Drug Utilization Code data element is composite field comprised of three distinct NCPDP data elements: "Reason for Service Code" (439-E4); "Professional Service Code" (440-E5); and "Result of Service Code" (441-E6). All 3 of these NCPDP fields are situationally required and independent of one another. Pharmacists may report none, one, two or all three. NCPDP situational rules call for one or more of these values in situations where the field(s) could result in different coverage, pricing, patient financial responsibility, drug utilization review outcome, or if the information affects payment for, or documentation of, professional pharmacy service. The NCPDP "Reasons of Service Code" (bytes 1 & 2 of the T-MSIS DRUG-UTILIZATION-CODE) explains whether the pharmacist filled the prescription, filled part of the prescription, etc. The NCPDP "Professional Service Code" (bytes 3 & 4 of the T-MSIS Drug Utilization Code) describes what the pharmacist did for the patient. The NCPDP "Result of Service Code" (bytes 5 & 6 of the T-MSIS Drug Utilization Code) describes the action the pharmacist took in response to a conflict or the result of a pharmacist"s professional service. Because the T-MSIS Drug Utilization Code data element is a composite field, it is necessary for the state to populate all six bytes if any of the three NCPDP fields has a value. In such situations, use "spaces" as placeholders for not applicable codes. |
| 09/12/2024 |
3.29.0 |
CRX.003.141 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value may include up to 6 digits to the left of the decimal point, and 2 digits to the right e.g. 123456.784. Mandatory |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Value may include up to 6 digits to the left of the decimal point, and 2 digits to the right e.g. 123456.784. Mandatory |
| 09/12/2024 |
3.29.0 |
CRX.003.136 |
UPDATE |
Coding requirement |
1. Value must be in HCBS Taxonomy Code List (VVL).2. Value must be 5 characters or less3. Conditional |
1. Value must be in HCBS Taxonomy Code List (VVL)2. Value must be 5 characters or less3. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.003.135 |
UPDATE |
Coding requirement |
1. Value must be in HCBS Service Code List (VVL).2. Value must be 1 character3. If value is 1-7, then HCBS Taxonomy must be populated.4. Conditional |
1. Value must be in HCBS Service Code List (VVL)2. Value must be 1 character3. If value is in [1-7], then HCBS Taxonomy must be populated.4. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.003.134 |
UPDATE |
Coding requirement |
1. Value must be 3 characters2. Mandatory3. Value must be in ['011', '018', '033', '034', '036', '085', '089', '127', '131', '136', '137', '145'] |
1. Value must be 3 characters2. Mandatory3. Value must be in [011,018,033,034,036,085,089,127,131,136,137,145] |
| 09/12/2024 |
3.29.0 |
CRX.003.133 |
UPDATE |
Coding requirement |
1. Value must be in NDC Unit of Measure List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in NDC Unit of Measure List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.003.132 |
UPDATE |
Coding requirement |
1. Value may include up to 8 digits to the left of the decimal point, and 3 digits to the right e.g. 12345678.9992. Conditional3. If Type of Claim is in [1, 3, A, C, U, W], then this value must be reported.4. When populated, corresponding Unit of Measure must be populated |
1. Value may include up to 8 digits to the left of the decimal point, and 3 digits to the right e.g. 12345678.9992. Conditional3. If Type of Claim is in [1,3,A,C,U,W], then this value must be reported.4. When populated, corresponding Unit of Measure must be populated |
| 09/12/2024 |
3.29.0 |
CRX.003.129 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is "0", then the value must not be populated.4. Conditional5. If value is populated, Crossover Indicator must be equal to "1" |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. If associated Crossover Indicator value is "0", then the value must not be populated.4. Conditional5. If value is populated, Crossover Indicator must be equal to "1" |
| 09/12/2024 |
3.29.0 |
CRX.003.128 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Medicare Combined Deductible Indicator is '1', then value must not be populated (or must be 99998)4. Value must not be populated if Medicare Deductible Amount is not populated5. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. If associated Medicare Combined Deductible Indicator is "1", then value must not be populated (or must be 99998)4. Value must not be populated if Medicare Deductible Amount is not populated5. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.003.127 |
UPDATE |
Definition |
The amount paid by Medicaid/CHIP on this claim at the claim line level toward the beneficiary's Medicare deductible. If the Medicare deductible amount can be identified separately from Medicare coinsurance payments, code that amount in this field. If the Medicare coinsurance and deductible payments cannot be separated, fill this field with the combined payment amount and Medicare Coinsurance Payment is not required. |
The amount paid by Medicaid/CHIP on this claim at the claim line level toward the beneficiary"s Medicare deductible. If the Medicare deductible amount can be identified separately from Medicare coinsurance payments, code that amount in this field. If the Medicare coinsurance and deductible payments cannot be separated, fill this field with the combined payment amount and Medicare Coinsurance Payment is not required. |
| 09/12/2024 |
3.29.0 |
CRX.003.127 |
UPDATE |
Coding requirement |
Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional4. If associated Crossover Indicator value is '0' (not a crossover claim), value should not be populated5. If value is greater than '0,' then Crossover Indicator must be '1' |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional4. If associated Crossover Indicator value is "0" (not a crossover claim), then value should not be populated5. If value is greater than "0", then Crossover Indicator must be "1" |
| 09/12/2024 |
3.29.0 |
CRX.003.126 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Type of Claim value equals '3, C, W', then value is mandatory and must be provided4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. If associated Type of Claim value in [3,C,W], then value is mandatory and must be provided4. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.003.125 |
UPDATE |
Definition |
The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
The amount paid to the provider by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.
For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 09/12/2024 |
3.29.0 |
CRX.003.125 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.003.124 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.003.122 |
UPDATE |
Definition |
The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed care encounters the Allowed Amount is determined by the managed care organization.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity allowed at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
The maximum amount displayed at the claim line level as determined by the payer as being "allowable" under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state"s MMIS (or PBM). On managed care encounters the Allowed Amount is determined by the managed care organization.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity allowed at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.
For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 09/12/2024 |
3.29.0 |
CRX.003.122 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.003.121 |
UPDATE |
Definition |
The amount billed at the claim detail level as submitted by the provider. For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed the managed care plan.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the provider billed the sub-capitated entity at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
The amount billed at the claim detail level as submitted by the provider. For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed the managed care plan.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the provider billed the sub-capitated entity at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.
For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 09/12/2024 |
3.29.0 |
CRX.003.121 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.003.119 |
UPDATE |
Coding requirement |
1. Value must be in Claim Status List (VVL)2. Value must be 3 characters or less3. Conditional4. If value in [545, 585, 654], then Claim Denied Indicator must be '0' and Claim Status Category must be 'F2' |
1. Value must be in Claim Status List (VVL)2. Value must be 3 characters or less3. Conditional4. If value in [545,585,654], then Claim Denied Indicator must be "0" and Claim Status Category must be "F2" |
| 03/14/2025 |
3.35.0 |
CRX.003.118 |
UPDATE |
Necessity |
Mandatory |
Conditional |
| 03/14/2025 |
3.35.0 |
CRX.003.118 |
UPDATE |
Coding requirement |
1. Value must be 12 characters or less2. Mandatory |
1. Value must be 12 characters or less2. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.003.116 |
UPDATE |
Coding requirement |
1. Value must be in Line 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. Conditional6. If associated Line Adjustment Number is populated, then value must be populated |
1. Value must be in Line 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. Conditional6. If associated Line Adjustment Number is populated, then value must be populated |
| 09/12/2024 |
3.29.0 |
CRX.003.115 |
UPDATE |
Coding requirement |
1. Value must be 3 characters or less2. If associated Line Adjustment Indicator value is 0, then value must not be populated3. If associated Line Adjustment Indicator value is 1, then value is mandatory and must be provided4. Conditional5. When populated, value must be one or greater |
1. Value must be 3 characters or less2. If associated Line Adjustment Indicator value is 0, then value must not be populated3. If associated Line Adjustment Indicator value is "1", then value is mandatory and must be provided4. Conditional5. When populated, value must be one or greater |
| 09/12/2024 |
3.29.0 |
CRX.003.113 |
UPDATE |
Coding requirement |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [‘4’, ‘1’] then value must be populated |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is "0", then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [4,1], then value must be populated |
| 09/12/2024 |
3.29.0 |
CRX.003.111 |
UPDATE |
Coding requirement |
1. Mandatory2. Value must be 20 characters or less3. When TYPE-OF-CLAIM = 4, D or X (lump sum payment), value must begin with an '&' |
1. Mandatory2. Value must be 20 characters or less3. When TYPE-OF-CLAIM is in [4,D,X] (lump sum payment), value must begin with an "&" |
| 09/12/2024 |
3.29.0 |
CRX.002.166 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (eg. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.165 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (eg. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.164 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (eg. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.163 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (eg. 100.50)3. Conditional |
| 12/10/2024 |
3.33.0 |
CRX.002.162 |
UPDATE |
Medicaid valid value info |
|
See https://www.ncpdp.org/ |
| 09/12/2024 |
3.29.0 |
CRX.002.160 |
UPDATE |
Coding requirement |
1. Value must be in Medicare Combined Deductible Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If value equals '1', then Total Medicare Coinsurance amount must not be populated.5. If value equals '0', then Crossover Indicator must equals '0'6. If value equals '1', then Crossover Indicator must equals '1'7. Conditional |
1. Value must be in Medicare Combined Deductible Indicator List (VVL)2. Value must be 1 character3. Value must be in [0,1] or not populated4. If value equals "1", then Total Medicare Coinsurance amount must not be populated5. If value equals "0", then Crossover Indicator must equals "0"6. If value equals "1", then Crossover Indicator must equals "1"7. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.156 |
UPDATE |
Coding requirement |
1. Value must be 30 characters or less2. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match Submitting State Provider ID (PRV.002.019) or3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match Provider Identifier (PRV.005.081) where the Provider Identifier Type (PRV.005.077) = '1'4. Mandatory |
1. Value must be 30 characters or less2. When Type of Claim not in [Z,3,C,W,2,B,V,4,D,X] then value may match Submitting State Provider ID (PRV.002.019) or3. When Type of Claim not in [Z,3,C,W,2,B,V,4,D,X] then value may match Provider Identifier (PRV.005.081) where the Provider Identifier Type (PRV.005.077) equals "1"4. Mandatory |
| 09/12/2024 |
3.29.0 |
CRX.002.105 |
UPDATE |
Coding requirement |
1. Conditional2. Value must be an 11-character string3. Character 1 must be numeric values 1 thru 94. Character 2 must be alphabetic values A thru Z (minus S, L, O, I, B, Z)5. Character 3 must be alphanumeric values 0 thru 9 or A thru Z (minus S, L, O, I, B, Z)6. Character 4 must be numeric values 0 thru 97. Character 5 must be alphabetic values A thru Z (minus S, L, O, I, B, Z)8. Character 6 must be alphanumeric values 0 thru 9 or A thru Z (minus S, L, O, I, B, Z)9. Character 7 must be numeric values 0 thru 910. Character 8 must be alphabetic values A thru Z (minus S, L, O, I, B, Z)11. Character 9 must be alphabetic values A thru Z (minus S, L, O, I, B, Z)12. Character 10 must be numeric values 0 thru 913. Character 11 must be numeric values 0 thru 914. Value must not contain a pipe or asterisk symbols |
1. Conditional2. Value must be an 11-character string3. Character 1 must be numeric values 1 thru 94. Character 2 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)5. Character 3 must be alphanumeric values 0 thru 9 or A thru Z (minus S,L,O,I,B,Z)6. Character 4 must be numeric values 0 thru 97. Character 5 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)8. Character 6 must be alphanumeric values 0 thru 9 or A thru Z (minus S,L,O,I,B,Z)9. Character 7 must be numeric values 0 thru 910. Character 8 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)11. Character 9 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)12. Character 10 must be numeric values 0 thru 913. Character 11 must be numeric values 0 thru 914. Value must not contain a pipe or asterisk symbols |
| 09/12/2024 |
3.29.0 |
CRX.002.104 |
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. Conditional4. Value must exist in the NPPES NPI data file |
| 09/12/2024 |
3.29.0 |
CRX.002.102 |
UPDATE |
Coding requirement |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to '2'3. When Type of Claim not in ('3','C','W') then value must match Provider Identifier (PRV.005.081)4. Mandatory5. Value must exist in the NPPES NPI data file6. 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 (PRV.005.007) equal to "2"3. When Type of Claim not in [3,C,W] then value must match Provider Identifier (PRV.005.081)4. Mandatory5. Value must exist in the NPPES NPI data file6. Nppes Entity Type Code associate with this NPI must equal "1" (Individual) |
| 09/12/2024 |
3.29.0 |
CRX.002.100 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Situational |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (eg. 100.50)3. Situational |
| 09/12/2024 |
3.29.0 |
CRX.002.098 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Situational |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (eg. 100.50)3. Situational |
| 09/12/2024 |
3.29.0 |
CRX.002.094 |
UPDATE |
Coding requirement |
1. Value must be in Claim Denied Indicator List (VVL)2. If value is '0', then Claim Status Category must equal "F2"3. Value must be 1 character4. Mandatory |
1. Value must be in Claim Denied Indicator List (VVL)2. If value is "0", then Claim Status Category must equal "F2"3. Value must be 1 character4. Mandatory |
| 09/12/2024 |
3.29.0 |
CRX.002.093 |
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. Must have an associated Beneficiary Deductible 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. Must have an associated Beneficiary Deductible Amount4. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.092 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (eg. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.088 |
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. Must have an associated Beneficiary 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. Must have an associated Beneficiary Coinsurance Amount4. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.090 |
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. Must have an associated Beneficiary Copayment 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. Must have an associated Beneficiary Copayment Amount4. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.089 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (eg. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.087 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (eg. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.086 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Compound Drug Indicator List (VVL)4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in Compound Drug Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.085 |
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. Value must be on or before associated End of Time Period (CRX.001.010)4. Value must be on or after associated Start of Time Period (CRX.001.009)5. Value must be on or after associated Date Prescribed (CRX.002.084)6. Value must be on or after associated eligible party's Date of Birth (ELG.002.024)7. Value must be on or before associated eligible party's Date of Death (ELG.002.025)8. Value must be populated when Adjustment Indicator (CRX.002.025) does not equal '1' and Type of Claim (CRX.002.029) does not equal 'Z'9. 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. Value must be on or before associated End of Time Period (CRX.001.010)4. Value must be on or after associated Start of Time Period (CRX.001.009)5. Value must be on or after associated Date Prescribed (CRX.002.084)6. Value must be on or after associated eligible party's Date of Birth (ELG.002.024)7. Value must be on or before associated eligible party's Date of Death (ELG.002.025)8. Value must be populated when Adjustment Indicator (CRX.002.025) does not equal "1" and Type of Claim (CRX.002.029) does not equal "Z"9. Mandatory |
| 09/12/2024 |
3.29.0 |
CRX.002.084 |
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. Value must be on or after associated eligible party's Date of Birth (ELG.002.024)4. Value must be on or before associated Prescription Fill Date (CRX.002.085)5. Value must be on or before associated Adjudication Date (CRX.002.027)6. Value must be on or before associated eligible party's Date of Death (ELG.002.025)7. Mandatory8. Value should be on or before End of Time Period (CRX.001.010) |
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. Value must be on or after associated eligible party's Date of Birth (ELG.002.024)4. Value must be on or before associated Prescription Fill Date (CRX.002.085)5. Value must be on or before associated Adjudication Date (CRX.002.027)6. Value must be on or before associated eligible party's Date of Death (ELG.002.025)7. Mandatory8. Value should be on or before End of Time Period (CRX.001.010) |
| 09/12/2024 |
3.29.0 |
CRX.002.082 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Border State Indicator List (VVL)4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in Border State Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.079 |
UPDATE |
Coding requirement |
1. Conditional2. Value must be 12 characters or less3. Value must not contain a pipe or asterisk symbols4. (Not Dual Eligible) if Dual Eligible Code (ELG.DE.085) value = "00", then value must not be populated.5. Value must be populated when Crossover Indicator (CRX.002.023) equals '1' and Medicare Beneficiary Identifier (CRX.002.105) must not be populated. |
1. Conditional2. Value must be 12 characters or less3. Value must not contain a pipe or asterisk symbols4. (Not Dual Eligible) if Dual Eligible Code (ELG.De085) value = "00", then value must not be populated5. Value must be populated when Crossover Indicator (CRX.002.023) equals "1" and Medicare Beneficiary Identifier (CRX.002.105) must not be populated |
| 09/12/2024 |
3.29.0 |
CRX.002.073 |
UPDATE |
Coding requirement |
1. Value must be in Provider Specialty List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in Provider Specialty List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.071 |
UPDATE |
Coding requirement |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to '2'3. Value must exist in the NPPES NPI data file4. Conditional5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal '01'6. When Type of Claim is in ['1','3','A','C'], then value must be populated7. When Type of Claim not in ('3','C','W') then value must match Provider Identifier (PRV.002.081) 8. NPPES Entity Type Code associated with this NPI must equal ‘2’ (Organization) |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to "2"3. Value must exist in the NPPES NPI data file4. Conditional5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal "01"6. When Type of Claim is in [1,3,A,C], then value must be populated7. When Type of Claim not in [3,C,W] then value must match Provider Identifier (PRV.002.081)8. NPPES Entity Type Code associated with this NPI must equal "2" (Organization) |
| 09/12/2024 |
3.29.0 |
CRX.002.070 |
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.002.019) Submitting State Provider ID or4. 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 where the Provider Identifier Type (PRV.005.081) equal to '1' 5. When Type of Claim is in ['1','3','A','C'], then value must be populated 6. 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)7. Prescription Fill Date (CRX.002.085) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or 8. Prescription Fill Date (CRX.002.085) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) |
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.002.019) Submitting State Provider ID or4. 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 where the Provider Identifier Type (PRV.005.081) equal to "1"5. When Type of Claim is in [1,3,A,C], then value must be populated6. 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)7. Prescription Fill Date (CRX.002.085) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or8. Prescription Fill Date (CRX.002.085) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) |
| 09/12/2024 |
3.29.0 |
CRX.002.069 |
UPDATE |
Coding requirement |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by a version number [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Conditional |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be "01" or in [21-30](1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20,32,33]6. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.068 |
UPDATE |
Coding requirement |
1. Value must be in Waiver Type List (VVL)2. Value must be 2 characters3. Value must match Eligible Waiver Type (ELG.012.173) for the enrollee for the same time period (by date of service)4. Value must have a corresponding value in Waive ID (CRX.002.069)5. Conditional6. Value must be in [ '06', '07', '08', '09', '10', '11', '12', '13', '14', '15', '16', '17', '18', '19', '20', '33'] when associated Program Type equals "07" |
1. Value must be in Waiver Type List (VVL)2. Value must be 2 characters3. Value must match Eligible Waiver Type (ELG.012.173) for the enrollee for the same time period (by date of service)4. Value must have a corresponding value in Waive ID (CRX.002.069)5. Conditional6. Value must be in [06,07,08,09,10,11,12,13,14,15,16,17,18,19,20,33] when associated Program Type equals "07" |
| 09/12/2024 |
3.29.0 |
CRX.002.067 |
UPDATE |
Coding requirement |
1. Value must be in Health Home Provider Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If there is an associated Health Home Entity Name value, then value must be "1"5. Conditional |
1. Value must be in Health Home Provider Indicator List (VVL)2. Value must be 1 character3. Value must be in [0,1] or not populated4. If there is an associated Health Home Entity Name value, then value must be "1"5. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.066 |
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. 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. Mandatory |
| 09/12/2024 |
3.29.0 |
CRX.002.061 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Forced 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 Forced Claim Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.060 |
UPDATE |
Coding requirement |
1. Value must be a positive integer2. Value must be between 0:9999 (inclusive)3. Value must not include commas or other non-numeric characters4. Value must be equal to the number of claim lines (e.g. Original Claim Line Number or Adjustment Claim Line Number instances) reported in the associated claim record being reported5. Value must be 4 characters or less6. Mandatory |
1. Value must be a positive integer2. Value must be between 0:9999 (inclusive)3. Value must not include commas or other non-numeric characters4. Value must be equal to the number of claim lines (eg. Original Claim Line Number or Adjustment Claim Line Number instances) reported in the associated claim record being reported5. Value must be 4 characters or less6. Mandatory |
| 09/12/2024 |
3.29.0 |
CRX.002.059 |
UPDATE |
Coding requirement |
1. Value must be in Medicare Reimbursement Type List (VVL)2. Value is mandatory and must be provided, when Crossover Indicator is equal to '1' (Crossover Claim)3. Value must be 2 characters4. Conditional |
1. Value must be in Medicare Reimbursement Type List (VVL)2. Value is mandatory and must be provided, when Crossover Indicator is equal to "1" (Crossover Claim)3. Value must be 2 characters4. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.058 |
UPDATE |
Definition |
The field denotes whether the payment amount was determined at the claim header or line/detail level.For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines’ associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only.For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header.For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed.For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
The field denotes whether the payment amount was determined at the claim header or line/detail level.
For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines’ associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only.
For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header.
For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed.
For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
| 09/12/2024 |
3.29.0 |
CRX.002.056 |
UPDATE |
Coding requirement |
1. Value must be 12 characters or less2. Value must not contain a pipe or asterisk symbols3. Conditional4. Value must match Managed Care Plan ID (ELG.014.192)5. Value must match State Plan ID Number (MCR.002.019)6. Value should be populated when Type of Claim (CRX.002.029) is in [3, C, W, 2, B, V]7. When Type of Claim in (3, C, W, 2, B, V) value must have a Managed Care Enrollment (ELG.014) for the beneficiary where the Prescription Fill Date (CRX.002.085) occurs between the managed care plan enrollment eff/end dates (ELG.014.197/198)8. When Type of Claim in (3, C, W, 2, B, V) value must have a Managed Care Main Record (MCR.002) for the plan where the Prescription Fill Date (CRX.002.085) occurs between the managed care contract eff/end dates (MCR.002.020/021) |
1. Value must be 12 characters or less2. Value must not contain a pipe or asterisk symbols3. Conditional4. Value must match Managed Care Plan ID (ELG.014.192)5. Value must match State Plan ID Number (MCR.002.019)6. Value should be populated when Type of Claim (CRX.002.029) is in [3,C,W,2,B,V]7. When Type of Claim in [3,C,W,2,B,V] value must have a Managed Care Enrollment (ELG.014) for the beneficiary where the Prescription Fill Date (CRX.002.085) occurs between the managed care plan enrollment eff/end dates (ELG.014.197/198)8. When Type of Claim in [3,C,W,2,B,V] value must have a Managed Care Main Record (MCR.002) for the plan where the Prescription Fill Date (CRX.002.085) occurs between the managed care contract eff/end dates (MCR.002.020/021) |
| 09/12/2024 |
3.29.0 |
CRX.002.055 |
UPDATE |
Coding requirement |
1. Value must be in Program Type List (VVL)2. Value must be 2 characters3. Mandatory4. (Community First Choice) If value equals '11', then State Plan Option Type (ELG.011.163) must equal '01' for the same time period5. If value equals '13', then State Plan Option Type (ELG.011.163) must equal '02' for the same time period |
1. Value must be in Program Type List (VVL)2. Value must be 2 characters3. Mandatory4. (Community First Choice) If value equals "11", then State Plan Option Type (ELG.011.163) must equal "01" for the same time period5. If value equals "13", then State Plan Option Type (ELG.011.163) must equal "02" for the same time period |
| 09/12/2024 |
3.29.0 |
CRX.002.054 |
UPDATE |
Coding requirement |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Value must be populated if TYPE-OF-CLAIM <> ‘3', ‘C’, ‘W’, or '6’4. Conditional |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Value must be populated if Type of Claim in not in [3,C,W,6]4. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.053 |
UPDATE |
Coding requirement |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Value must be populated if TYPE-OF-CLAIM <> ‘3', ‘C’, ‘W’, or '6’4. Conditional |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Value must be populated if Type of Claim in not in [3,C,W,6]4. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.052 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Fixed Payment Indicator List (VVL)4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in Fixed Payment Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.051 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Type of Claim value is in [4, D, or X], then value is mandatory and must be provided4. Conditional5. When populated, Service Tracking Type must be populated6. When populated, Total Medicaid Amount must not be populated |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (eg. 100.50)3. If associated Type of Claim value is in [4,D,X], then value is mandatory and must be provided4. Conditional5. When populated, Service Tracking Type must be populated6. When populated, Total Medicaid Amount must not be populated |
| 09/12/2024 |
3.29.0 |
CRX.002.050 |
UPDATE |
Coding requirement |
1. Value must be in Service Tracking Type List (VVL)2. (Service Tracking Claim) if associated Type of Claim is in ['4','D', 'X'] then value is mandatory and must be reported3. Value must be 2 characters4. Conditional |
1. Value must be in Service Tracking Type List (VVL)2. (Service Tracking Claim) if associated Type of Claim is in [4,D,X] then value is mandatory and must be reported3. Value must be 2 characters4. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.048 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Other Insurance Indicator List (VVL)4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in Other Insurance Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.047 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (eg. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.045 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than associated Total Billed Amount - (Total Medicare Coinsurance Amount + Total Medicare Deductible Amount)4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (eg. 100.50)3. Value must be less than associated Total Billed Amount - (Total Medicare Coinsurance Amount + Total Medicare Deductible Amount)4. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.044 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated.4. Conditional5. If associated Medicare Combined Deductible Indicator is '1', then value must not be populated6. When populated, value must be less than or equal to Total Billed Amount |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (eg. 100.50)3. If associated Crossover Indicator value is "0" (not a crossover claim), then value should not be populated4. Conditional5. If associated Medicare Combined Deductible Indicator is "1", then value must not be populated6. When populated, value must be less than or equal to Total Billed Amount |
| 09/12/2024 |
3.29.0 |
CRX.002.043 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated.4. Conditional5. When populated, value must be less than or equal to Total Billed Amount |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (eg. 100.50)3. If associated Crossover Indicator value is "0" (not a crossover claim), then value should not be populated4. Conditional5. When populated, value must be less than or equal to Total Billed Amount |
| 09/12/2024 |
3.29.0 |
CRX.002.041 |
UPDATE |
Definition |
The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider. |
The total amount paid to the provider by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider.
|
| 09/12/2024 |
3.29.0 |
CRX.002.041 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must be populated, when Type of Claim is in [‘1’, ‘A’]8. Value must not be populated or equal to ‘0.00’ when associated Claim Status is in ['26', '026', '87', '087', '542', '585', '654']9. Value should not be populated, when associated Type of Claim value is in [‘4’, ‘D’] |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (eg. 100.50)3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals "2", value must equal the sum of line level Medicaid Paid Amounts6. Conditional7. Value must be populated, when Type of Claim is in [1,A]8. Value must not be populated or equal to ‘0.00’ when associated Claim Status is in [26,026,87,087,542,585,654]9. Value should not be populated, when associated Type of Claim value is in [4,D] |
| 09/12/2024 |
3.29.0 |
CRX.002.040 |
UPDATE |
Definition |
The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. On managed care encounters the Allowed Amount is determined by the managed care organization.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity allowed for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
The claim header level maximum amount determined by the payer as being "allowable" under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state"s MMIS. On managed care encounters the Allowed Amount is determined by the managed care organization.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity allowed for the service. Report a null value in this field if the provider is a sub-capitated network provider.
For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 09/12/2024 |
3.29.0 |
CRX.002.040 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. When populated and Payment Level Indicator = '2' then value must equal the sum of all claim line Allowed Amount values4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (eg. 100.50)3. When populated and Payment Level Indicator = "2" then value must equal the sum of all claim line Allowed Amount values4. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.039 |
UPDATE |
Definition |
The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. Report a null value in this field if the provider is a sub-capitated network provider.
For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 09/12/2024 |
3.29.0 |
CRX.002.039 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must equal the sum of all Billed Amount instances for the associated claim4. Conditional5. When associated Type of Claim in [‘1’, ’3’, ’A’, ’C’], value must be populated |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (eg. 100.50)3. Value must equal the sum of all Billed Amount instances for the associated claim4. Conditional5. When associated Type of Claim in [1,3,A,C] and Source Location does not equal "23", value must be populated |
| 09/12/2024 |
3.29.0 |
CRX.002.034 |
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. Must have an associated Check Number4. 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. Must have an associated Check Number4. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.032 |
UPDATE |
Definition |
The field denotes the claims payment system from which the claim was extracted.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = '22' to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis.For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = '23' to indicate that the sub-capitated network provider provided the service directly to the enrollee.For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = “23” to indicate that the sub-capitated network provider provided the service directly to the enrollee. |
The field denotes the claims payment system from which the claim was extracted.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = "22" to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis.
For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = "23" to indicate that the sub-capitated network provider provided the service directly to the enrollee.
For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = “23” to indicate that the sub-capitated network provider provided the service directly to the enrollee. |
| 09/12/2024 |
3.29.0 |
CRX.002.031 |
UPDATE |
Coding requirement |
1. Value must be in Claim Status Category List (VVL)2. (Denied Claim) if associated Claim Denied Indicator indicates the claim was denied, then value must be "F2"3. (Denied Claim) if associated Claim Status is in [ 542, 585, 654 ], then value must be "F2"4. Value must be 3 characters or less5. Mandatory |
1. Value must be in Claim Status Category List (VVL)2. (Denied Claim) if associated Claim Denied Indicator indicates the claim was denied, then value must be "F2"3. (Denied Claim) if associated Claim Status is in [542,585,654], then value must be "F2"4. Value must be 3 characters or less5. Mandatory |
| 09/12/2024 |
3.29.0 |
CRX.002.030 |
UPDATE |
Coding requirement |
1. Value must be in Claim Status List (VVL)2. Value must be 3 characters or less3. Conditional4. If value in [ 542, 585, 654 ], Claim Denied Indicator must be '0' and Claim Status Category must be 'F2' |
1. Value must be in Claim Status List (VVL)2. Value must be 3 characters or less3. Conditional4. If value in [ 542, 585, 654 ], Claim Denied Indicator must be "0" and Claim Status Category must be 'F2' |
| 09/12/2024 |
3.29.0 |
CRX.002.029 |
UPDATE |
Definition |
A code to indicate what type of payment is covered in this claim.For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record. |
A code to indicate what type of payment is covered in this claim.
For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = "3" for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record. |
| 09/12/2024 |
3.29.0 |
CRX.002.029 |
UPDATE |
Coding requirement |
1. Value must be in Type of Claim List (VVL)2. Value must be 1 character3. Mandatory4. When value equals 'Z', claim denied indicator must equal '0' |
1. Value must be in Type of Claim List (VVL)2. Value must be 1 character3. Mandatory4. When value equals "Z", claim denied indicator must equal "0" |
| 09/12/2024 |
3.29.0 |
CRX.002.028 |
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. Must have an associated Total Medicaid Paid Amount4. 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. Must have an associated Total Medicaid Paid Amount4. Mandatory |
| 09/12/2024 |
3.29.0 |
CRX.002.027 |
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. Value should be on or before End of Time Period value found in associated T-MSIS File Header Record4. 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. Value should be on or before End of Time Period value found in associated T-MSIS File Header Record4. Mandatory |
| 09/12/2024 |
3.29.0 |
CRX.002.024 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Conditional5. When value equals '0', is invalid or not populated, the associated 1115A Demonstration Indicator (ELG.018.233) must equal '0', is invalid or not populated |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Conditional5. When value equals "0", is invalid or not populated, the associated 1115A Demonstration Indicator (ELG.018.233) must equal "0", is invalid or not populated |
| 09/12/2024 |
3.29.0 |
CRX.002.023 |
UPDATE |
Coding requirement |
1. Value must be in Crossover Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service)5. If the Type of Claim value is in ["1", "3", "A", "C"], then value is mandatory and must be reported.6. Conditional |
1. Value must be in Crossover Indicator List (VVL)2. Value must be 1 character3. Value must be in [0,1] or not populated4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in [01,02,04,08,09,10] for the same time period (by date of service)5. If the Type of Claim value is in [1,3,A,C], then value is mandatory and must be reported6. Conditional |
| 03/14/2025 |
3.35.0 |
CRX.002.021 |
UPDATE |
Necessity |
Mandatory |
Conditional |
| 03/14/2025 |
3.35.0 |
CRX.002.021 |
UPDATE |
Coding requirement |
1. Value must be 12 characters or less2. Mandatory |
1. Value must be 12 characters or less2. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.020 |
UPDATE |
Coding requirement |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [‘4’, ‘1’] then value must be populated |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [4,1] then value must be populated |
| 09/12/2024 |
3.29.0 |
CRX.001.011 |
UPDATE |
Coding requirement |
1. For production files, value must be equal to 'P'2. Value must be in File Status Indicator List (VVL)3. Value must be 1 character4. Mandatory |
1. For production files, value must be equal to "P"2. Value must be in File Status Indicator List (VVL)3. Value must be 1 character4. Mandatory |
| 09/12/2024 |
3.29.0 |
CRX.001.006 |
UPDATE |
Coding requirement |
1. Value must equal 'CLAIM-RX'2. Mandatory |
1. Value must equal "CLAIM-RX"2. Mandatory |
| 09/12/2024 |
3.29.0 |
COT.003.234 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1]3. Mandatory |
1. Value must be 1 character2. Value must be in [0,1]3. Mandatory |
| 09/12/2024 |
3.29.0 |
COT.003.225 |
UPDATE |
Coding requirement |
1. Value may include up to 8 digits to the left of the decimal point, and 3 digits to the right e.g. 12345678.9992. Conditional |
1. Value may include up to 8 digits to the left of the decimal point and 3 digits to the right e.g. 12345678.9992. Conditional |
| 09/12/2024 |
3.29.0 |
COT.003.224 |
UPDATE |
Coding requirement |
1. Value must be in NDC Unit of Measure List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in NDC Unit of Measure List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
COT.003.213 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
COT.003.212 |
UPDATE |
Coding requirement |
1. Value must be in XXI MBESCBES Category of Service List (VVL)2. Conditional3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is '02', then a valid value is mandatory and must be reported4. If XIX MBESCBES Category of Service is populated then value must not be populated5. Value must be 3 characters or less |
1. Value must be in XXI MBESCBES Category of Service List (VVL)2. Conditional3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is "02",then a valid value is mandatory and must be reported4. If XIX MBESCBES Category of Service is populated then value must not be populated5. Value must be 3 characters or less |
| 09/12/2024 |
3.29.0 |
COT.003.211 |
UPDATE |
Coding requirement |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is '01', then a valid value is mandatory and must be reported5. If value is in ['14', '35', '42' or '44'], then Sex (ELG.002.023) must not equals 'M'6. If XXI MBESCBES Category of Service is populated then must not be populated |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is "01",then a valid value is mandatory and must be reported5. If value is in [14,35,42,44],then Sex (ELG.002.023) must not equals "M"6. If XXI MBESCBES Category of Service is populated then must not be populated |
| 09/12/2024 |
3.29.0 |
COT.003.210 |
UPDATE |
Coding requirement |
1. Value must be in CMS 64 Category for Federal Reimbursement List (VVL)2. Value must be 2 characters3. (Federal Funding under Title XXI) if value equals '02', then the eligible's CHIP Code (ELG.003.054) must be in ['2', '3']4. (Federal Funding under Title XIX) if value equals '01' then the eligible's CHIP Code (ELG.003.054) must be '1'5. Conditional6. If Type of Claim is in ['1','2','5','A','B','E','U','V','Y'] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported.7. If Type of Claim is in ['4','D'] and the Service Tracking Payment Amount on the relevant record is populated, then value must be reported. |
1. Value must be in CMS 64 Category for Federal Reimbursement List (VVL)2. Value must be 2 characters3. (Federal Funding under Title XXI) if value equals "02", then the eligibles CHIP Code (ELG.003.054) must be in [2,3]4. (Federal Funding under Title XIX) if value equals "01", then the eligibles CHIP Code (ELG.003.054) must be "1"5. Conditional6. If Type of Claim is in [1,2,5,A,B,E,U,V,Y] and the Total Medicaid Paid Amount is populated on the corresponding claim header,then value must be reported7. If Type of Claim is in [4,D] and the Service Tracking Payment Amount on the relevant record is populated,then value must be reported |
| 09/12/2024 |
3.29.0 |
COT.003.198 |
UPDATE |
Coding requirement |
1. Value must be in Tooth Surface Code List (VVL)2. Value must be 1 character3. Conditional4. When populated, associated type of service value must be in [013, 029, 035] |
1. Value must be in Tooth Surface Code List (VVL)2. Value must be 1 character3. Conditional4. When populated,associated type of service value must be in [013,029,035] |
| 09/12/2024 |
3.29.0 |
COT.003.197 |
UPDATE |
Coding requirement |
1. Value must be in Tooth Quad Code List (VVL)2. Value must be 2 characters3. Conditional4. When populated, associated type of service value must be in [013, 029, 035] |
1. Value must be in Tooth Quad Code List (VVL)2. Value must be 2 characters3. Conditional4. When populated,associated type of service value must be in [013,029,035] |
| 09/12/2024 |
3.29.0 |
COT.003.196 |
UPDATE |
Coding requirement |
1. Value must be in Tooth Number List (VVL)2. If Tooth Designation System (COT.003.195) is 'JP' value must be found in [1..32][51-82][A..T]or [AS..KS]3. If Tooth Designation System (COT.003.195) is 'JO' value must have 1 digit before and after the decimal (N.N)4. If Tooth Designation System (COT.003.195) is 'JO' value must be a first digit of 1-4 and the decimal must be between 1-85. Value must be 2 characters or less6. Conditional7. When value is in ['A'-'T'], the difference between Ending Date of Service (COT.002.034) and Date of Birth (COT.002.108) is less than 15 years |
1. Value must be in Tooth Number List (VVL)2. If Tooth Designation System (COT.003.195) is "JP" value must be found in [1-32][51-82][A-T]or [AS-KS]3. If Tooth Designation System (COT.003.195) is "JO" value must have 1 digit before and after the decimal (N.N)4. If Tooth Designation System (COT.003.195) is "JO" value must be a first digit of 1-4 and the decimal must be between 1-85. Value must be 2 characters or less6. Conditional7. When value is in [A-T], the difference between Ending Date of Service (COT.002.034) and Date of Birth (COT.002.108) is less than 15 years |
| 09/12/2024 |
3.29.0 |
COT.003.193 |
UPDATE |
Coding requirement |
1. Value must be in Provider Specialty List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in Provider Specialty List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
COT.003.192 |
UPDATE |
Coding requirement |
1. Value must be in Provider Type Code List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in Provider Type Code List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
COT.003.188 |
UPDATE |
Coding requirement |
1. Value must be in HCBS Taxonomy Code List (VVL).2. Value must be 5 characters or less3. Conditional |
1. Value must be in HCBS Taxonomy Code List (VVL)2. Value must be 5 characters or less3. Conditional |
| 09/12/2024 |
3.29.0 |
COT.003.187 |
UPDATE |
Coding requirement |
1. Value must be in HCBS Service Code List (VVL).2. Value must be 1 character3. If value is 1-7, then HCBS Taxonomy must be populated.4. Conditional |
1. Value must be in HCBS Service Code List (VVL)2. Value must be 1 character3. If value is in [1-7], then HCBS Taxonomy must be populated4. Conditional |
| 09/12/2024 |
3.29.0 |
COT.003.186 |
UPDATE |
Coding requirement |
1. Value must be 3 characters2. Mandatory3. When value is in [119-122], Servicing Provider NPI Num (COT.002.190) should not be populated4. Value must be in ['002', '003', '004', '005', '006', '007', '008', '010', '011', '012', '013', '014', '015', '016', '017', '018', '019', '020', '021', '022', '023', '024', '025', '026', '027', '028', '029', '030', '031', '032', '035', '036', '037', '038', '039', '040', '041', '042', '043', '049', '050', '051', '052', '053', '054', '055', '056', '057', '058', '060', '061', '062', '063', '064', '065', '066', '067', '068', '069', '070', '071', '072', '073', '074', '075', '076', '077', '078', '079', '080', '081', '082', '083', '084', '085', '086', '087', '088', '089', '115', '119', '120', '121', '122', '127', '131', '134', '135', '136', '137', '138', '139', '140', '141', '142', '143', '144', '145', '147']5. When value is in [119-122], Servicing Provider Taxonomy (COT.003.191) should not be populated6. When value is in [119-122], Referring Provider NPI Num (COT.002.118) should not be populated7. Value must be 3 characters8. Mandatory9. When value is in [119-122], Billing Provider NPI Num (COT.002.113) should not be populated10. When value is in [119-122], Billing Provider Taxonomy (COT.002.114) should not be populated11. When value is in [119-122], Referring Provider Taxonomy (COT.002.119) should not be populated12. When value is not in ['025','085'], Sex (ELG.002.023) equals 'M'13. When value is in [119-122], Servicing Provider Num (COT.002.189) should not be populated |
1. Value must be 3 characters2. Mandatory3. When value is in [119-122],Servicing Provider NPI Num (COT.002.190) should not be populated4. Value must be in [002,003,004,005,006,007,008,010,011,012,013,014,015,016,017,018,019,020,021,022,023,024,025,026,027,028,029,030,031,032,035,036,037,038,039,040,041,042,043,049,050,051,052,053,054,055,056,057,058,060,061,062,063,064,065,066,067,068,069,070,071,072,073,074,075,076,077,078,079,080,081,082,083,084,085,086,087,088,089,115,119,120,121,122,127,131,134,135,136,137,138,139,140,141,142,143,144,145,147]5. When value is in [119-122], Servicing Provider Taxonomy (COT.003.191) should not be populated6. When value is in [119-122], Referring Provider NPI Num (COT.002.118) should not be populated7. Value must be 3 characters8. When value is in [119-122], Billing Provider NPI Num (COT.002.113) should not be populated9. When value is in [119-122], Billing Provider Taxonomy (COT.002.114) should not be populated10. When value is in [119-122], Referring Provider Taxonomy (COT.002.119) should not be populated11. When value is not in [025,085], Sex (ELG.002.023) equals "M"12. When value is in [119-122], Servicing Provider Num (COT.002.189) should not be populated |
| 09/12/2024 |
3.29.0 |
COT.003.184 |
UPDATE |
Coding requirement |
1. Value may include up to 8 digits to the left of the decimal point, and 3 digits to the right e.g. 12345678.9992. Conditional |
1. Value may include up to 8 digits to the left of the decimal point and 3 digits to the right e.g. 12345678.9992. Conditional |
| 09/12/2024 |
3.29.0 |
COT.003.183 |
UPDATE |
Coding requirement |
1. Value may include up to 8 digits to the left of the decimal point, and 3 digits to the right e.g. 12345678.9992. Conditional3. If Type of Claim is in [1, 3, A, C, U, W], then this value must be reported.4. When populated, corresponding Unit of Measure must be populated |
1. Value may include up to 8 digits to the left of the decimal point and 3 digits to the right e.g. 12345678.9992. Conditional3. If Type of Claim is in [1,3,A,C,U,W], then this value must be reported4. When populated,corresponding Unit of Measure must be populated |
| 09/12/2024 |
3.29.0 |
COT.003.182 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is "0", then the value must not be populated.4. Conditional5. If value is populated, Crossover Indicator must be equal to "1" |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. If associated Crossover Indicator value is "0", then the value must not be populated4. Conditional5. If value is populated, Crossover Indicator must be equal to "1" |
| 09/12/2024 |
3.29.0 |
COT.003.179 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Type of Claim value equals '3, C, W', then value is mandatory and must be provided4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. If associated Type of Claim value equals [3,C,W],then value is mandatory and must be provided4. Conditional |
| 09/12/2024 |
3.29.0 |
COT.003.178 |
UPDATE |
Definition |
The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.
For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field.
|
| 09/12/2024 |
3.29.0 |
COT.003.178 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional4. Value should not be populated or equal to zero, when associated Claim Line Status is in ['26', '026', '87', '087', '542', '585', '654'] |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional4. Value should not be populated or equal to zero,when associated Claim Line Status is in [26,026,87,087,542,585,654] |
| 09/12/2024 |
3.29.0 |
COT.003.177 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
COT.003.176 |
UPDATE |
Coding requirement |
1. Situational2. Value must be between -99999999999.99 and 99999999999.993. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )4. Value must be 11 digits or less left of the decimal i.e. 9999999999 99 |
1. Situational2. Value must be between -99999999999.99 and 99999999999.993. Value must be expressed as a number with 2-digit precision (e.g. 100.50)4. Value must be 11 digits or less left of the decimal i.e. 9999999999 99 |
| 09/12/2024 |
3.29.0 |
COT.003.175 |
UPDATE |
Definition |
The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed care encounters the Allowed Amount is determined by the managed care organization.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity allowed at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed care encounters the Allowed Amount is determined by the managed care organization.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity allowed at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.
For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 09/12/2024 |
3.29.0 |
COT.003.175 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional4. When Type of Claim is in ['1', 'A'}, Medicaid Paid Amount (COT.003.177) is less than or equal to the value submitted |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional4. When Type of Claim is in [1,A], Medicaid Paid Amount (COT.003.177) is less than or equal to the value submitted |
| 09/12/2024 |
3.29.0 |
COT.003.174 |
UPDATE |
Definition |
The amount billed at the claim detail level as submitted by the provider. For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed the managed care plan.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the provider billed the sub-capitated entity at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
The amount billed at the claim detail level as submitted by the provider. For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed the managed care plan.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the provider billed the sub-capitated entity at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.
For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 09/12/2024 |
3.29.0 |
COT.003.174 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
COT.003.173 |
UPDATE |
Coding requirement |
Not Applicable |
|
| 09/12/2024 |
3.29.0 |
COT.003.171 |
UPDATE |
Coding requirement |
1. When populated, there must be a corresponding Procedure Code2. Value must be in Procedure Code Flag List (VVL)3. Value must be 2 characters4. Conditional |
1. When populated,there must be a corresponding Procedure Code2. Value must be in Procedure Code Flag List (VVL)3. Value must be 2 characters4. Conditional |
| 09/12/2024 |
3.29.0 |
COT.003.168 |
UPDATE |
Coding requirement |
1. Value must be in Revenue Code List (VVL)2. A Revenue Code value requires an associated Revenue Charge3. Value must be 4 characters or less4. Conditional |
1. Value must be in Revenue Code List (VVL)2. When Source Location does not equal “23”, value requires an associated Revenue Charge3. Value must be 4 characters or less4. Conditional5. When populated, Type of Bill must be populated |
| 09/12/2024 |
3.29.0 |
COT.003.167 |
UPDATE |
Definition |
For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, the date on which the service covered by this claim ended. For capitation premium payments, the date on which the period of coverage related to this payment ends/ended. For financial transactions reported to the OT file, populate with the last day of the time period covered by this financial transaction.For sub-capitation payments, this represents the last date of the period the sub-capitation payment covers. |
For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, the date on which the service covered by this claim ended. For capitation premium payments, the date on which the period of coverage related to this payment ends/ended. For financial transactions reported to the OT file, populate with the last day of the time period covered by this financial transaction.
For sub-capitation payments, this represents the last date of the period the sub-capitation payment covers. |
| 09/12/2024 |
3.29.0 |
COT.003.167 |
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 |
COT.003.166 |
UPDATE |
Definition |
For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, this would be the date on which the service covered by this claim began. For capitation premium payments, the date on which the period of coverage related to this payment began. For financial transactions reported to the OT file, populate with the first day of the time period covered by this financial transaction.For sub-capitation payments, this represents the first date of the period the sub-capitation payment covers. |
For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, this would be the date on which the service covered by this claim began. For capitation premium payments, the date on which the period of coverage related to this payment began. For financial transactions reported to the OT file, populate with the first day of the time period covered by this financial transaction.
For sub-capitation payments, this represents the first date of the period the sub-capitation payment covers. |
| 09/12/2024 |
3.29.0 |
COT.003.166 |
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 eligibles Enrollment End Date (ELG.021.254) values8. Mandatory |
| 09/12/2024 |
3.29.0 |
COT.003.165 |
UPDATE |
Coding requirement |
1. Value must be in Claim Status List (VVL)2. Value must be 3 characters or less3. Conditional4. If value in [545, 585, 654], then Claim Denied Indicator must be '0' and Claim Status Category must be 'F2' |
1. Value must be in Claim Status List (VVL)2. Value must be 3 characters or less3. Conditional4. If value in [545,585,654],then Claim Denied Indicator must be 0 and Claim Status Category must be "F2" |
| 09/12/2024 |
3.29.0 |
COT.003.162 |
UPDATE |
Coding requirement |
1. Value must be in Line 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. Conditional6. If associated Line Adjustment Number is populated, then value must be populated |
1. Value must be in Line 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. Conditional6. If associated Line Adjustment Number is populated, then value must be populated |
| 09/12/2024 |
3.29.0 |
COT.003.161 |
UPDATE |
Coding requirement |
1. Value must be 3 characters or less2. If associated Line Adjustment Indicator value is 0, then value must not be populated3. If associated Line Adjustment Indicator value is 1, then value is mandatory and must be provided4. Conditional5. When populated, value must be one or greater |
1. Value must be 3 characters or less2. If associated Line Adjustment Indicator value is "0", then value must not be populated3. If associated Line Adjustment Indicator value is "1", then value is mandatory and must be provided4. Conditional5. When populated,value must be one or greater |
| 09/12/2024 |
3.29.0 |
COT.003.160 |
UPDATE |
Coding requirement |
1. Value must be 3 characters or less2. Value must not contain a pipe or asterisk symbols3. Mandatory4. When populated, value must be one or greater |
1. Value must be 3 characters or less2. Value must not contain a pipe or asterisk symbols3. Mandatory4. When populated,value must be one or greater |
| 09/12/2024 |
3.29.0 |
COT.003.159 |
UPDATE |
Coding requirement |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [‘4’, ‘1’] then value must be populated |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is "0", then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [4,1], then value must be populated |
| 09/12/2024 |
3.29.0 |
COT.003.157 |
UPDATE |
Definition |
A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
| 09/12/2024 |
3.29.0 |
COT.003.157 |
UPDATE |
Coding requirement |
1. Mandatory2. Value must be 20 characters or less3. When Type of Claim (COT.002.037) equals 4, D or X (lump sum payment) value must begin with an '&' |
1. Mandatory2. Value must be 20 characters or less3. When Type of Claim (COT.002.037) is in [4,D,X] (lump sum payment) value must begin with an "&" |
| 09/12/2024 |
3.29.0 |
COT.002.233 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.232 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.231 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.230 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.229 |
UPDATE |
Definition |
The NPI of Ordering Provider represents the individual who requested the service or items being reported on this service line. Example include, but are not limited to, provider ordering diagnostic tests and medical equipment or supplies.[Ordering provider information is only captured at the line level in the X12 837P format but in v3.0.0 of the T-MSIS file layout it is only captured at the header level. This discrepancy will be addressed in a future version of the T-MSIS OT file layout. Until Ordering provider information has been moved from the T-MSIS claim header to the line, there is no need to report it at the header.] |
The NPI of Ordering Provider represents the individual who requested the service or items being reported on this service line. Example include, but are not limited to, provider ordering diagnostic tests and medical equipment or supplies.
[Ordering provider information is only captured at the line level in the X12 837P format but in v3.0.0 of the T-MSIS file layout it is only captured at the header level. This discrepancy will be addressed in a future version of the T-MSIS OT file layout. Until Ordering provider information has been moved from the T-MSIS claim header to the line, there is no need to report it at the header.] |
| 09/12/2024 |
3.29.0 |
COT.002.229 |
UPDATE |
Coding requirement |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type (PRV.005.007) 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 (PRV.005.007) equal to "2"3. Conditional4. Value must exist in the NPPES NPI data file |
| 09/12/2024 |
3.29.0 |
COT.002.150 |
UPDATE |
Coding requirement |
Not Applicable |
|
| 09/12/2024 |
3.29.0 |
COT.002.147 |
UPDATE |
Coding requirement |
1. Conditional2. Value must be an 11-character string3. Character 1 must be numeric values 1 thru 94. Character 2 must be alphabetic values A thru Z (minus S, L, O, I, B, Z)5. Character 3 must be alphanumeric values 0 thru 9 or A thru Z (minus S, L, O, I, B, Z)6. Character 4 must be numeric values 0 thru 97. Character 5 must be alphabetic values A thru Z (minus S, L, O, I, B, Z)8. Character 6 must be alphanumeric values 0 thru 9 or A thru Z (minus S, L, O, I, B, Z)9. Character 7 must be numeric values 0 thru 910. Character 8 must be alphabetic values A thru Z (minus S, L, O, I, B, Z)11. Character 9 must be alphabetic values A thru Z (minus S, L, O, I, B, Z)12. Character 10 must be numeric values 0 thru 913. Character 11 must be numeric values 0 thru 914. Value must not contain a pipe or asterisk symbols |
1. Conditional2. Value must be an 11-character string3. Character 1 must be numeric values 1 thru 94. Character 2 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)5. Character 3 must be alphanumeric values 0 thru 9 or A thru Z (minus S,L,O,I,B,Z)6. Character 4 must be numeric values 0 thru 97. Character 5 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)8. Character 6 must be alphanumeric values 0 thru 9 or A thru Z (minus S,L,O,I,B,Z)9. Character 7 must be numeric values 0 thru 910. Character 8 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)11. Character 9 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)12. Character 10 must be numeric values 0 thru 913. Character 11 must be numeric values 0 thru 914. Value must not contain a pipe or asterisk symbols |
| 09/12/2024 |
3.29.0 |
COT.002.146 |
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 Service (COT.003.186) equals '121', value must not be populated5. 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. Conditional4. When Type of Service (COT.003.186) equals "121", value must not be populated5. Value must exist in the NPPES NPI data file |
| 09/12/2024 |
3.29.0 |
COT.002.142 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Situational |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Situational |
| 09/12/2024 |
3.29.0 |
COT.002.140 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Situational |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Situational |
| 09/12/2024 |
3.29.0 |
COT.002.138 |
UPDATE |
Coding requirement |
1. Value must not contain a pipe or asterisk symbols2. Value must 50 characters or less3. Conditional4. Value must be populated when an associated Type of Service (COT.003.186) equals ‘138’ (payment for health home services)5. Value must be populated when an associated claim line has a XIX MBESCBES Category of Service (COT.003.211) equals ‘45’ (health homes for substance use services) |
1. Value must not contain a pipe or asterisk symbols2. Value must 50 characters or less3. Conditional4. Value must be populated when an associated Type of Service (COT.003.186) equals "138" (payment for health home services)5. Value must be populated when an associated claim line has a XIX MBESCBES Category of Service (COT.003.211) equals "45" (health homes for substance use services) |
| 09/12/2024 |
3.29.0 |
COT.002.137 |
UPDATE |
Coding requirement |
1. Value must be in Copayment Waived Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1]4. Situational |
1. Value must be in Copayment Waived Indicator List (VVL)2. Value must be 1 character3. Value must be in [0,1]4. Situational |
| 09/12/2024 |
3.29.0 |
COT.002.136 |
UPDATE |
Coding requirement |
1. Value must be in Claim Denied Indicator List (VVL)2. If value is '0', then Claim Status Category must equal "F2"3. Value must be 1 character4. Mandatory |
1. Value must be in Claim Denied Indicator List (VVL)2. If value is "0", then Claim Status Category must equal "F2"3. Value must be 1 character4. Mandatory |
| 09/12/2024 |
3.29.0 |
COT.002.134 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.132 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.130 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.128 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Border State Indicator List (VVL)4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in Border State Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.123 |
UPDATE |
Coding requirement |
1. Value must be in Place of Service Code List (VVL)2. Value must be 2 characters3. Conditional4. If value is populated on a non-denied claim, then Procedure Code (COT.003.169) must be populated.5. When Type of Service (COT.003.186) is in [119-122], Place of Service (COT.002.123) should not be populated |
1. Value must be in Place of Service Code List (VVL)2. Value must be 2 characters3. Conditional4. If value is populated on a non-denied claim, then Procedure Code (COT.003.169) must be populated5. When Type of Service (COT.003.186) is in [119-122], value should not be populated |
| 09/12/2024 |
3.29.0 |
COT.002.122 |
UPDATE |
Coding requirement |
1. Conditional2. Value must be 12 characters or less3. Value must not contain a pipe or asterisk symbols4. (Not Dual Eligible) if Dual Eligible Code (ELG.DE.085) value = "00", then value must not be populated.5. Value must be populated when Crossover Indicator (COT.002.023) equals '1' and Medicare Beneficiary Identifier (COT.002.147) is not populated. |
1. Conditional2. Value must be 12 characters or less3. Value must not contain a pipe or asterisk symbols4. (Not Dual Eligible) if Dual Eligible Code (ELG.DE.085) value equals "00", then value must not be populated5. Value must be populated when Crossover Indicator (COT.002.023) equals "1" and Medicare Beneficiary Identifier (COT.002.147) is not populated |
| 09/12/2024 |
3.29.0 |
COT.002.118 |
UPDATE |
Coding requirement |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Value must be in the NPPES NPI data file4. Conditional |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to "2"3. Value must be in the NPPES NPI data file4. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.116 |
UPDATE |
Coding requirement |
1. Value must be in Provider Specialty List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in Provider Specialty List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.115 |
UPDATE |
Coding requirement |
1. Value must be in Provider Type Code List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in Provider Type Code List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.114 |
UPDATE |
Coding requirement |
1. Value must be in Provider Taxonomy List (VVL)2. Value must be 12 characters or less3. Conditional4. Value is in [119, 120, 121, 122 ], then value should not be populated |
1. Value must be in Provider Taxonomy List (VVL)2. Value must be 12 characters or less3. Conditional4. If Type of Service (COT.003.186) is in [119,120,121,122], then value should not be populated |
| 09/12/2024 |
3.29.0 |
COT.002.113 |
UPDATE |
Definition |
The National Provider ID (NPI) of the billing entity responsible for billing a patient for healthcare services. The billing provider can also be servicing, referring, or prescribing provider. Can be admitting provider except for Long Term Care.For sub-capitation payments, report the national provider identifier (NPI) for the sub-capitated entity if the provider has one. |
The National Provider ID (NPI) of the billing entity responsible for billing a patient for healthcare services. The billing provider can also be servicing, referring, or prescribing provider. Can be admitting provider except for Long Term Care.
For sub-capitation payments, report the national provider identifier (NPI) for the sub-capitated entity if the provider has one. |
| 09/12/2024 |
3.29.0 |
COT.002.113 |
UPDATE |
Coding requirement |
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 (COT.002.037) not in ('3','C','W') then value must match Provider Identifier (PRV.002.081) |
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.002.081)6. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal '01'7. NPPES Entity Type Code associated with this NPI must equal ‘2’ (Organization) |
| 09/12/2024 |
3.29.0 |
COT.002.112 |
UPDATE |
Definition |
A unique identification number assigned by the state to a provider or capitation plan. This data element should represent the entity billing for the service. For encounter records, if associated Type of Claim value equals 3, C, or W, then value must be the state identifier of the provider or entity (billing or reporting) to the managed care plan.For sub-capitation payments, report the state-assigned provider identifier for the sub-capitated entity, when available or required. |
A unique identification number assigned by the state to a provider or capitation plan. This data element should represent the entity billing for the service. For encounter records, if associated Type of Claim value equals 3, C, or W, then value must be the state identifier of the provider or entity (billing or reporting) to the managed care plan.
For sub-capitation payments, report the state-assigned provider identifier for the sub-capitated entity, when available or required. |
| 09/12/2024 |
3.29.0 |
COT.002.112 |
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.002.019) Submitting State Provider ID or4. 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 where the Provider Identifier Type (PRV.005.081) equal to '1' 5. When Type of Claim is in ['1','3','A','C'], then value must be populated6. 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)7. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or8. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080)9. When Type of Service (COT.003.186) is not in ['119', ‘120’, ‘122’], value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1' |
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.002.019) Submitting State Provider ID or4. 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 where the Provider Identifier Type (PRV.005.081) equal to "1"5. When Type of Claim is in [1,3,A,C], then value must be populated6. When Type of Claim is 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)7. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or8. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080)9. When Type of Service (COT.003.186) is not in [119,120,122], value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to "1" |
| 09/12/2024 |
3.29.0 |
COT.002.111 |
UPDATE |
Coding requirement |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by a version number [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Conditional |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be "01" or in [21-30](1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.110 |
UPDATE |
Coding requirement |
1. Value must be in Waiver Type List (VVL)2. Value must be 2 characters3. Value must match Eligible Waiver Type (ELG.012.173) for the enrollee for the same time period (by date of service)4. When populated, Waiver ID (COT.002.111) must be populated5. Conditional6. Value must be in [ '06', '07', '08', '09', '10', '11', '12', '13', '14', '15', '16', '17', '18', '19', '20', '33'] when associated Program Type equals "07" |
1. Value must be in Waiver Type List (VVL)2. Value must be 2 characters3. Value must match Eligible Waiver Type (ELG.012.173) for the enrollee for the same time period (by date of service)4. When populated, Waiver ID (COT.002.111) must be populated5. Conditional6. Value must be in [06,07,08,09,10,11,12,13,14,15,16,17,18,19,20, 33] when associated Program Type equals "07" |
| 09/12/2024 |
3.29.0 |
COT.002.109 |
UPDATE |
Coding requirement |
1. Value must be in Health Home Provider Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If there is an associated Health Home Entity Name value, then value must be "1"5. Conditional |
1. Value must be in Health Home Provider Indicator List (VVL)2. Value must be 1 character3. Value must be in [0,1] or not populated4. If there is an associated Health Home Entity Name value, then value must be "1"5. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.104 |
UPDATE |
Coding requirement |
1. Value must be 20 characters or less2. Value must not contain a pipe or asterisk symbol3. Conditional |
1. Value must be 20 characters or less2. Value must not contain a pipe or asterisk symbols3. Conditional |
| 02/27/2025 |
3.34.0 |
COT.002.083 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
| 02/27/2025 |
3.34.0 |
COT.002.082 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
| 02/27/2025 |
3.34.0 |
COT.002.081 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
| 02/27/2025 |
3.34.0 |
COT.002.080 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
| 02/27/2025 |
3.34.0 |
COT.002.079 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
| 02/27/2025 |
3.34.0 |
COT.002.078 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
| 02/27/2025 |
3.34.0 |
COT.002.077 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
| 02/27/2025 |
3.34.0 |
COT.002.076 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
| 02/27/2025 |
3.34.0 |
COT.002.075 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
| 02/27/2025 |
3.34.0 |
COT.002.074 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
| 09/12/2024 |
3.29.0 |
COT.002.073 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Healthcare Acquired Condition Indicator List (VVL).4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in Healthcare Acquired Condition Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.072 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Forced 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 Forced Claim Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.069 |
UPDATE |
Coding requirement |
1. Value must be in Medicare Reimbursement Type List (VVL)2. Value is mandatory and must be provided, when Crossover Indicator is equal to '1' (Crossover Claim)3. Value must be 2 characters4. Conditional |
1. Value must be in Medicare Reimbursement Type List (VVL)2. Value is mandatory and must be provided, when Crossover Indicator is equal to "1" (Crossover Claim)3. Value must be 2 characters4. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.068 |
UPDATE |
Definition |
The field denotes whether the payment amount was determined at the claim header or line/detail level.For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines’ associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only.For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header.For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed.For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
The field denotes whether the payment amount was determined at the claim header or line/detail level.
For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines’ associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only.
For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header.
For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed.
For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
| 09/12/2024 |
3.29.0 |
COT.002.066 |
UPDATE |
Definition |
A unique number assigned by the state which represents a distinct comprehensive managed care plan, prepaid health plan, primary care case management program, a program for all-inclusive care for the elderly entity, or other approved plans.For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report the PLAN-ID-NUMBER for the MCP (MCO, PIHP, or PAHP that has a contract with a state) that is making the payment to the sub-capitated entity or sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
A unique number assigned by the state which represents a distinct comprehensive managed care plan, prepaid health plan, primary care case management program, a program for all-inclusive care for the elderly entity, or other approved plans.
For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report the PLAN-ID-NUMBER for the MCP (MCO, PIHP, or PAHP that has a contract with a state) that is making the payment to the sub-capitated entity or sub-capitated network provider.
For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 09/12/2024 |
3.29.0 |
COT.002.066 |
UPDATE |
Coding requirement |
1. Value must be 12 characters or less2. Value must not contain a pipe or asterisk symbols3. Conditional4. Value must match Managed Care Plan ID (ELG.014.192)5. Value must match State Plan ID Number (MCR.002.019)6. When Type of Claim (COT.002.037) in (3, C, W, 2, B, V) value must have a managed care enrollment (ELG.014) for the beneficiary where the Beginning DOS (COT.002.033) occurs between the managed care plan enrollment eff/end dates (ELG.014.197/198)7. When Type of Claim (COT.002.037) in (3, C, W, 2, B, V) value must have a managed care main record (MCR.002) for the plan where the Beginning DOS (COT.002.033) occurs between the managed care contract eff/end dates (MCR.002.020/021) |
1. Value must be 12 characters or less2. Value must not contain a pipe or asterisk symbols3. Conditional4. Value must match Managed Care Plan ID (ELG.014.192)5. Value must match State Plan ID Number (MCR.002.019)6. When Type of Claim (COT.002.037) in [3,C,W,2,B,V] value must have a managed care enrollment (ELG.014) for the beneficiary where the Beginning DOS (COT.002.033) occurs between the managed care plan enrollment eff/end dates (ELG.014.197/198)7. When Type of Claim (COT.002.037) in (3,C,W,2,B,V) value must have a managed care main record (MCR.002) for the plan where the Beginning DOS (COT.002.033) occurs between the managed care contract eff/end dates (MCR.002.020/021) |
| 09/12/2024 |
3.29.0 |
COT.002.065 |
UPDATE |
Coding requirement |
1. Value must be in Program Type List (VVL)2. Value must be 2 characters3. Mandatory4. (Community First Choice) If value equals '11', then State Plan Option Type (ELG.011.163) must equal '01' for the same time period5. If value equals '13', then State Plan Option Type (ELG.011.163) must equal '02' for the same time period |
1. Value must be in Program Type List (VVL)2. Value must be 2 characters3. Mandatory4. (Community First Choice) If value equals "11", then State Plan Option Type (ELG.011.163) must equal "01" for the same time period5. If value equals "13", then State Plan Option Type (ELG.011.163) must equal "02" for the same time period |
| 09/12/2024 |
3.29.0 |
COT.002.064 |
UPDATE |
Coding requirement |
1. Value must be in Medicare Combined Deductible Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If value equals '1', then Total Medicare Coinsurance amount must not be populated.5. If value equals '0', then Crossover Indicator must equals '0'6. If value equals '1', then Crossover Indicator must equals '1'7. Conditional |
1. Value must be in Medicare Combined Deductible Indicator List (VVL)2. Value must be 1 character3. Value must be in [0,1] or not populated4. If value equals "1", then Total Medicare Coinsurance amount must not be populated5. If value equals "0", then Crossover Indicator must equals "0"6. If value equals "1", then Crossover Indicator must equal "1"7. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.063 |
UPDATE |
Coding requirement |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Value must be populated if TYPE-OF-CLAIM <> ‘3', ‘C’, ‘W’, or '6’4. Conditional |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Value must be populated if Type of Claim is not in [3,C,W,6]4. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.062 |
UPDATE |
Coding requirement |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Value must be populated if TYPE-OF-CLAIM <> ‘3', ‘C’, ‘W’, or '6’4. Conditional |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Value must be populated if Type of Claim is not in [3,C,W,6]4. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.061 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Fixed Payment Indicator List (VVL)4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in Fixed Payment Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.060 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Type of Claim value is in [4, D, or X], then value is mandatory and must be provided4. Conditional5. When populated, Service Tracking Type must be populated6. When populated, Total Medicaid Amount must not be populated |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. If associated Type of Claim value is in [4,D,X]], then value is mandatory and must be provided4. Conditional5. When populated, Service Tracking Type must be populated6. When populated, Total Medicaid Amount must not be populated |
| 09/12/2024 |
3.29.0 |
COT.002.059 |
UPDATE |
Coding requirement |
1. Value must be in Service Tracking Type List (VVL)2. (Service Tracking Claim) if associated Type of Claim is in ['4','D', 'X'] then value is mandatory and must be reported3. Value must be 2 characters4. Conditional |
1. Value must be in Service Tracking Type List (VVL)2. (Service Tracking Claim) if associated Type of Claim is in [4,D,X] then value is mandatory and must be reported3. Value must be 2 characters4. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.057 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Other Insurance Indicator List (VVL)4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in Other Insurance Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.056 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.054 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than associated Total Billed Amount- (Total Medicare Coinsurance Amount + Total Medicare Deductible Amount)4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Value must be less than associated Total Billed Amount- (Total Medicare Coinsurance Amount + Total Medicare Deductible Amount)4. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.053 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated.4. Conditional5. If associated Medicare Combined Deductible Indicator is '1', then value must not be populated6. When populated, value must be less than or equal to Total Billed Amount |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. If associated Crossover Indicator value is "0" (not a crossover claim), then value should not be populated4. Conditional5. If associated Medicare Combined Deductible Indicator is "1", then value must not be populated6. When populated, value must be less than or equal to Total Billed Amount |
| 09/12/2024 |
3.29.0 |
COT.002.052 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated.4. Conditional5. When populated, value must be less than or equal to Total Billed Amount |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. If associated Crossover Indicator value is "0" (not a crossover claim), then value should not be populated4. Conditional5. When populated, value must be less than or equal to Total Billed Amount |
| 09/12/2024 |
3.29.0 |
COT.002.050 |
UPDATE |
Definition |
The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field.For sub-capitation payments, this represents the amount paid by the managed care plan to the sub-capitated entity. |
The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider.
For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field.
For sub-capitation payments, this represents the amount paid by the managed care plan to the sub-capitated entity. |
| 09/12/2024 |
3.29.0 |
COT.002.050 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must be populated, when Type of Claim is in [‘1’, ‘A’]8. Value must not be populated or equal to ‘0.00’ when associated Claim Status is in ['26', '026', '87', '087', '542', '585', '654']9. Value should not be populated, when associated Type of Claim value is in [‘4’, ‘D’] 10. Value must not be greater than Total Allowed Amount (COT.002.049) 11. Value must be populated, when Type of Claim (COT.002.037) is in [‘2’, '5', ‘B’, 'E'] |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals "2", value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must be populated, when Type of Claim is in [1,A]8. Value must not be populated or equal to ‘0.00’ when associated Claim Status is in [26,026,87,087,542,585,654]9. Value should not be populated, when associated Type of Claim value is in [4,D]10. Value must not be greater than Total Allowed Amount (COT.002.049)11. Value must be populated, when Type of Claim (COT.002.037) is in [2,5,B,E] |
| 09/12/2024 |
3.29.0 |
COT.002.049 |
UPDATE |
Definition |
The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. On managed care encounters the Allowed Amount is determined by the managed care organization.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity allowed for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
The claim header level maximum amount determined by the payer as being "allowable" under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state"s MMIS. On managed care encounters the Allowed Amount is determined by the managed care organization.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity allowed for the service. Report a null value in this field if the provider is a sub-capitated network provider.
For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 09/12/2024 |
3.29.0 |
COT.002.049 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. When populated and Payment Level Indicator = '2' then value must equal the sum of all claim line Allowed Amount values4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. When populated and Payment Level Indicator equals "2" then value must equal the sum of all claim line Allowed Amount values4. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.048 |
UPDATE |
Definition |
The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. Report a null value in this field if the provider is a sub-capitated network provider.
For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 09/12/2024 |
3.29.0 |
COT.002.048 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must equal the sum of all Billed Amount instances for the associated claim4. Conditional5. When associated Type of Claim in [‘1’, ’3’, ’A’, ’C’], value must be populated |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Value must equal the sum of all Billed Amount instances for the associated claim4. Conditional5. When associated Type of Claim in [1,3,A,C] and Source Location does not equal "23", value must be populated |
| 09/12/2024 |
3.29.0 |
COT.002.041 |
UPDATE |
Definition |
The field denotes the claims payment system from which the claim was extracted.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = '22' to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis.For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = '23' to indicate that the sub-capitated network provider provided the service directly to the enrollee.For sub-capitation payments, report a SOURCE-LOCATION of '20', indicating the managed care plan is the source of payment. |
The field denotes the claims payment system from which the claim was extracted.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = "22" to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis.
For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = "23" to indicate that the sub-capitated network provider provided the service directly to the enrollee.
For sub-capitation payments, report a SOURCE-LOCATION of "20", indicating the managed care plan is the source of payment. |
| 09/12/2024 |
3.29.0 |
COT.002.040 |
UPDATE |
Coding requirement |
1. Value must be in Claim Status Category List (VVL)2. (Denied Claim) if associated Claim Denied Indicator indicates the claim was denied, then value must be "F2"3. (Denied Claim) if associated Claim Status is in [ 542, 585, 654 ], then value must be "F2"4. Value must be 3 characters or less5. Mandatory |
1. Value must be in Claim Status Category List (VVL)2. (Denied Claim) if associated Claim Denied Indicator indicates the claim was denied, then value must be "F2"3. (Denied Claim) if associated Claim Status is in [542,585,654], then value must be "F2"4. Value must be 3 characters or less5. Mandatory |
| 09/12/2024 |
3.29.0 |
COT.002.039 |
UPDATE |
Coding requirement |
1. Value must be in Claim Status List (VVL)2. Value must be 3 characters or less3. Conditional4. If value in [ 542, 585, 654 ], Claim Denied Indicator must be '0' and Claim Status Category must be 'F2' |
1. Value must be in Claim Status List (VVL)2. Value must be 3 characters or less3. Conditional4. If value in [542,585,654], Claim Denied Indicator must be "0" and Claim Status Category must be "F2" |
| 09/12/2024 |
3.29.0 |
COT.002.038 |
UPDATE |
Coding requirement |
1. Value must be in Type of Bill List (VVL)2. Value must be 4 characters3. First character must be a '0'4. Conditional |
1. Value must be in Type of Bill List (VVL)2. Value must be 4 characters3. First character must be a "0"4. Conditional5. When populated, Revenue Code must be populated |
| 09/12/2024 |
3.29.0 |
COT.002.037 |
UPDATE |
Definition |
A code to indicate what type of payment is covered in this claim.For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record.For sub-capitation payments, report TYPE-OF-CLAIM = '6' or “F”. |
A code to indicate what type of payment is covered in this claim.
For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = "3" for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record.
For sub-capitation payments, report TYPE-OF-CLAIM = "6" or “F”. |
| 09/12/2024 |
3.29.0 |
COT.002.037 |
UPDATE |
Coding requirement |
1. Value must be in Type of Claim List (VVL)2. Value must be 1 character3. Mandatory4. When value equals 'Z', claim denied indicator must equal '0' |
1. Value must be in Type of Claim List (VVL)2. Value must be 1 character3. Mandatory4. When value equals "Z", claim denied indicator must equal "0" |
| 09/12/2024 |
3.29.0 |
COT.002.034 |
UPDATE |
Definition |
For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, the date on which the service covered by this claim ended. For capitation premium payments, the date on which the period of coverage related to this payment ends/ended. For financial transactions reported to the OT file, populate with the last day of the time period covered by this financial transaction.For sub-capitation payments, this represents the last date of the period the sub-capitation payment covers. |
For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, the date on which the service covered by this claim ended. For capitation premium payments, the date on which the period of coverage related to this payment ends/ended. For financial transactions reported to the OT file, populate with the last day of the time period covered by this financial transaction.
For sub-capitation payments, this represents the last date of the period the sub-capitation payment covers. |
| 09/12/2024 |
3.29.0 |
COT.002.034 |
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 |
COT.002.033 |
UPDATE |
Definition |
For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, this would be the date on which the service covered by this claim began. For capitation premium payments, the date on which the period of coverage related to this payment began. For financial transactions reported to the OT file, populate with the first day of the time period covered by this financial transaction.For sub-capitation payments, this represents the first date of the period the sub-capitation payment covers. |
For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, this would be the date on which the service covered by this claim began. For capitation premium payments, the date on which the period of coverage related to this payment began. For financial transactions reported to the OT file, populate with the first day of the time period covered by this financial transaction.
For sub-capitation payments, this represents the first date of the period the sub-capitation payment covers. |
| 09/12/2024 |
3.29.0 |
COT.002.033 |
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 |
| 09/12/2024 |
3.29.0 |
COT.002.024 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Conditional5. When value equals '0', is invalid or not populated, the associated 1115A Demonstration Indicator (ELG.018.233) must equal '0', is invalid or not populated |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Conditional5. When value equals "0", is invalid or not populated, the associated 1115A Demonstration Indicator (ELG.018.233) must equal "0", is invalid or not populated |
| 09/12/2024 |
3.29.0 |
COT.002.023 |
UPDATE |
Coding requirement |
1. Value must be in Crossover Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service)5. If the Type of Claim value is in ["1", "3", "A", "C"], then value is mandatory and must be reported.6. Conditional |
1. Value must be in Crossover Indicator List (VVL)2. Value must be 1 character3. Value must be in [0,1] or not populated4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in [01,02,04,08,09,10] for the same time period (by date of service)5. If the Type of Claim value is in [1,3,A,C], then value is mandatory and must be reported6. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.022 |
UPDATE |
Coding requirement |
1. Mandatory2. Value must be 20 characters or less3. Populated value must begin with an '&', when Type of Claim (COT.002.037) = 4, D or X (lump sum payment)4. Value must match MSIS Identification Number (ELG.021.251) and the Beginning Date of Service (COT.002.033) must be between Enrollment Effective Date (ELG.021.253) and Enrollment End Date (ELG.021.254) |
1. Mandatory2. Value must be 20 characters or less3. When Type of Claim (COT.002.037) in [4,D,X] (lump sum payment), value must begin with an "'&"4. Value must match MSIS Identification Number (ELG.021.251) and the Beginning Date of Service (COT.002.033) must be between Enrollment Effective Date (ELG.021.253) and Enrollment End Date (ELG.021.254) |
| 09/12/2024 |
3.29.0 |
COT.002.020 |
UPDATE |
Coding requirement |
Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [‘4’, ‘1’] then value must be populated |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is "0", then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [4,1] then value must be populated |
| 09/12/2024 |
3.29.0 |
COT.001.011 |
UPDATE |
Coding requirement |
1. For production files, value must be equal to 'P'2. Value must be in File Status Indicator List (VVL)3. Value must be 1 character4. Mandatory |
1. For production files, value must be equal to "P"2. Value must be in File Status Indicator List (VVL)3. Value must be 1 character4. Mandatory |
| 09/12/2024 |
3.29.0 |
COT.001.006 |
UPDATE |
Coding requirement |
1. Value must equal 'CLAIM-OT'2. Mandatory |
1. Value must equal "CLAIM-OT"2. Mandatory |
| 09/12/2024 |
3.29.0 |
CLT.003.243 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1]3. Mandatory |
1. Value must be 1 character2. Value must be in [0,1]3. Mandatory |
| 09/12/2024 |
3.29.0 |
CLT.003.229 |
UPDATE |
Coding requirement |
1. Value must be in NDC Unit of Measure List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in NDC Unit of Measure List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.003.225 |
UPDATE |
Coding requirement |
1. Value must be in XXI MBESCBES Category of Service List (VVL)2. Conditional3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is '02', then a valid value is mandatory and must be reported4. If XIX MBESCBES Category of Service is populated then value must not be populated5. Value must be 3 characters or less |
1. Value must be in XXI MBESCBES Category of Service List (VVL)2. Conditional3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is "02", then a valid value is mandatory and must be reported4. If XIX MBESCBES Category of Service is populated then value must not be populated5. Value must be 3 characters or less |
| 09/12/2024 |
3.29.0 |
CLT.003.224 |
UPDATE |
Coding requirement |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is '01', then a valid value is mandatory and must be reported5. If value is in ['14', '35', '42' or '44'], then Sex (ELG.002.023) must not equals 'M'6. If XXI MBESCBES Category of Service is populated then must not be populated |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is "01", then a valid value is mandatory and must be reported5. If value is in [14,35,42,44], then Sex (ELG.002.023) must not equal "M"6. If XXI MBESCBES Category of Service is populated, then must not be populated |
| 09/12/2024 |
3.29.0 |
CLT.003.219 |
UPDATE |
Coding requirement |
1. Value must be in CMS 64 Category for Federal Reimbursement List (VVL)2. Value must be 2 characters3. (Federal Funding under Title XXI) if value equals '02', then the eligible's CHIP Code (ELG.003.054) must be in ['2', '3']4. (Federal Funding under Title XIX) if value equals '01' then the eligible's CHIP Code (ELG.003.054) must be '1'5. Conditional6. If Type of Claim is in ['1','2','5','A','B','E','U','V','Y'] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported.7. If Type of Claim is in ['4','D'] and the Service Tracking Payment Amount on the relevant record is populated, then value must be reported. |
1. Value must be in CMS 64 Category for Federal Reimbursement List (VVL)2. Value must be 2 characters3. (Federal Funding under Title XXI) if value equals '02', then the eligible's CHIP Code (ELG.003.054) must be in [2,3]4. (Federal Funding under Title XIX) if value equals "01" then the eligible's CHIP Code (ELG.003.054) must be "1"5. Conditional6. If Type of Claim is in [1,2,5,A,B,E,U,V,Y] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported7. If Type of Claim is in [4,D] and the Service Tracking Payment Amount on the relevant record is populated, then value must be reported |
| 09/12/2024 |
3.29.0 |
CLT.003.216 |
UPDATE |
Coding requirement |
1. Value must be in Provider Specialty List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in Provider Specialty List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.003.215 |
UPDATE |
Coding requirement |
1. Value must be in Provider Type Code List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in Provider Type Code List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.003.211 |
UPDATE |
Coding requirement |
1. Value must be 3 characters2. Mandatory3. Value must be in ['009', '044', '045', '046', '047', '048', '050', '059', '133', '136', '137', '146', '147'] |
1. Value must be 3 characters2. Mandatory3. Value must be in [009,044,045,046,047,048,050,059,133,136,137,146,147] |
| 09/12/2024 |
3.29.0 |
CLT.003.210 |
UPDATE |
Coding requirement |
1. Value must be in Billing Unit List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in Billing Unit List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.003.209 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Type of Claim value equals '3, C, W', then value is mandatory and must be provided4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. If associated Type of Claim value is in [3,C,W], then value is mandatory and must be provided4. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.003.208 |
UPDATE |
Definition |
The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.
For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 09/12/2024 |
3.29.0 |
CLT.003.208 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional4. Value should not be populated or equal to zero, when associated Claim Line Status is in ['26', '026', '87', '087', '542', '585', '654'] |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional4. Value should not be populated or equal to zero, when associated Claim Line Status is in [26,026,87,087,542,585,654] |
| 09/12/2024 |
3.29.0 |
CLT.003.207 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.003.206 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.003.205 |
UPDATE |
Definition |
The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed care encounters the Allowed Amount is determined by the managed care organization.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity allowed at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
The maximum amount displayed at the claim line level as determined by the payer as being "allowable" under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state"s MMIS (or PBM). On managed care encounters the Allowed Amount is determined by the managed care organization.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity allowed at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.
For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 09/12/2024 |
3.29.0 |
CLT.003.205 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.003.204 |
UPDATE |
Definition |
The total amount billed for the related Revenue Code. Total amount billed includes both covered and non-covered charges (as defined by UB-04 Billing Manual). For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed to the managed care plan.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the provider billed the sub-capitated entity at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
The total amount billed for the related Revenue Code. Total amount billed includes both covered and non-covered charges (as defined by UB-04 Billing Manual). For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed to the managed care plan.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the provider billed the sub-capitated entity at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.
For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 09/12/2024 |
3.29.0 |
CLT.003.204 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than or equal to associated Total Billed Amount value.4. When populated, associated claim line Revenue Charge must be populated5. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Value must be less than or equal to associated Total Billed Amount value4. When populated and the Source Location does not equal “23”, the associated claim line Revenue Code must be populated5. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.003.203 |
UPDATE |
Definition |
On facility claim entries, this field is to capture maximum allowable quantity by revenue code category, e.g., number of days in a particular type of accommodation, pints of blood, etc. However, when HCPCS codes are required for services, the units are equal to the number of times the procedure/service being reported was performed. This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled. For CLAIMOT claims/encounter records use Service Quantity Actual and CLAIMRX claims/encounter records use the Prescription Quantity Actual field |
On facility claim entries, this field is to capture maximum allowable quantity by revenue code category, e.g., number of days in a particular type of accommodation, pints of blood, etc. However, when HCPCS codes are required for services, the units are equal to the number of times the procedure/service being reported was performed. This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled. For CLAIMOT claims/encounter records use Service Quantity Actual and CLAIMRX claims/encounter records use the Prescription Quantity Actual field. |
| 09/12/2024 |
3.29.0 |
CLT.003.202 |
UPDATE |
Definition |
On facility claim entries, this field is to capture the actual service quantity by revenue code category, e.g., number of days in a particular type of accommodation, pints of blood, etc. However, when HCPCS codes are required for services, the units are equal to the number of times the procedure/service being reported was performed. For CLAIMOT claims/encounter records use Service Quantity Actual and CLAIMRX claims/encounter records use the Prescription Quantity Actual field |
On facility claim entries, this field is to capture the actual service quantity by revenue code category, e.g., number of days in a particular type of accommodation, pints of blood, etc. However, when HCPCS codes are required for services, the units are equal to the number of times the procedure/service being reported was performed. For CLAIMOT claims/encounter records use Service Quantity Actual and CLAIMRX claims/encounter records use the Prescription Quantity Actual field. |
| 09/12/2024 |
3.29.0 |
CLT.003.201 |
UPDATE |
Coding requirement |
Not Applicable |
|
| 09/12/2024 |
3.29.0 |
CLT.003.198 |
UPDATE |
Coding requirement |
1. Value must be in Revenue Code List (VVL)2. A Revenue Code value requires an associated Revenue Charge3. Value must be 4 characters or less4. Mandatory |
1. Value must be in Revenue Code List (VVL)2. When Source Location does not equal “23”, value requires an associated Revenue Charge3. Value must be 4 characters or less4. Mandatory |
| 09/12/2024 |
3.29.0 |
CLT.003.197 |
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 |
CLT.003.196 |
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 |
| 09/12/2024 |
3.29.0 |
CLT.003.195 |
UPDATE |
Coding requirement |
1. Value must be in Claim Status List (VVL)2. Value must be 3 characters or less3. Conditional4. If value in [545, 585, 654], then Claim Denied Indicator must be '0' and Claim Status Category must be 'F2' |
1. Value must be in Claim Status List (VVL)2. Value must be 3 characters or less3. Conditional4. If value in [545,585,654], then Claim Denied Indicator must be "1" and Claim Status Category must be "F2" |
| 09/12/2024 |
3.29.0 |
CLT.003.192 |
UPDATE |
Coding requirement |
1. Value must be in Line 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. Conditional6. If associated Line Adjustment Number is populated, then value must be populated |
1. Value must be in Line 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. Conditional6. If associated Line Adjustment Number is populated, then value must be populated |
| 09/12/2024 |
3.29.0 |
CLT.003.191 |
UPDATE |
Coding requirement |
1. Value must be 3 characters or less2. If associated Line Adjustment Indicator value is 0, then value must not be populated3. If associated Line Adjustment Indicator value is 1, then value is mandatory and must be provided4. Conditional5. When populated, value must be one or greater |
1. Value must be 3 characters or less2. If associated Line Adjustment Indicator value is "0", then value must not be populated3. If associated Line Adjustment Indicator value is "1", then value is mandatory and must be provided4. Conditional5. When populated, value must be one or greater |
| 09/12/2024 |
3.29.0 |
CLT.003.189 |
UPDATE |
Coding requirement |
Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [‘4’, ‘1’] then value must be populated |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is "0", then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [4,1], then value must be populated |
| 09/12/2024 |
3.29.0 |
CLT.003.187 |
UPDATE |
Coding requirement |
1. Mandatory2. Value must be 20 characters or less3. When Type of Claim (CLT.002.052) equals 4, D or X (lump sum payment) value must begin with an '&' |
1. Mandatory2. Value must be 20 characters or less3. When Type of Claim (CLT.002.052) is in [4,D,X] (lump sum payment) value must begin with an "&" |
| 09/12/2024 |
3.29.0 |
CLT.002.242 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.241 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.240 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.239 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.179 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is "0", then the value must not be populated.4. Conditional5. If value is populated, Crossover Indicator must be equal to "1" |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. If associated Crossover Indicator value is "0", then the value must not be populated4. Conditional5. If value is populated, Crossover Indicator must be equal to "1" |
| 09/12/2024 |
3.29.0 |
CLT.002.178 |
UPDATE |
Coding requirement |
1. Value must be in Provider Type Code List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in Provider Type Code List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.176 |
UPDATE |
Coding requirement |
1. Value must be in Provider Specialty List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in Provider Specialty List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.174 |
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 data file |
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 data file |
| 09/12/2024 |
3.29.0 |
CLT.002.168 |
UPDATE |
Coding requirement |
1. Conditional2. Value must be an 11-character string3. Character 1 must be numeric values 1 thru 94. Character 2 must be alphabetic values A thru Z (minus S, L, O, I, B, Z)5. Character 3 must be alphanumeric values 0 thru 9 or A thru Z (minus S, L, O, I, B, Z)6. Character 4 must be numeric values 0 thru 97. Character 5 must be alphabetic values A thru Z (minus S, L, O, I, B, Z)8. Character 6 must be alphanumeric values 0 thru 9 or A thru Z (minus S, L, O, I, B, Z)9. Character 7 must be numeric values 0 thru 910. Character 8 must be alphabetic values A thru Z (minus S, L, O, I, B, Z)11. Character 9 must be alphabetic values A thru Z (minus S, L, O, I, B, Z)12. Character 10 must be numeric values 0 thru 913. Character 11 must be numeric values 0 thru 914. Value must not contain a pipe or asterisk symbols |
1. Conditional2. Value must be an 11-character string3. Character 1 must be numeric values 1 thru 94. Character 2 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)5. Character 3 must be alphanumeric values 0 thru 9 or A thru Z (minus S,L,O,I,B,Z)6. Character 4 must be numeric values 0 thru 97. Character 5 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)8. Character 6 must be alphanumeric values 0 thru 9 or A thru Z (minus S,L,O,I,B,Z)9. Character 7 must be numeric values 0 thru 910. Character 8 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)11. Character 9 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)12. Character 10 must be numeric values 0 thru 913. Character 11 must be numeric values 0 thru 914. Value must not contain a pipe or asterisk symbols |
| 09/12/2024 |
3.29.0 |
CLT.002.167 |
UPDATE |
Coding requirement |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to '2'3. Value must exist in the NPPES NPI data file4. Conditional |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to "2"3. Value must exist in the NPPES NPI data file4. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.165 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Situational |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Situational |
| 09/12/2024 |
3.29.0 |
CLT.002.163 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Situational |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Situational |
| 09/12/2024 |
3.29.0 |
CLT.002.159 |
UPDATE |
Coding requirement |
1. Value must be in Claim Denied Indicator List (VVL)2. If value is '0', then Claim Status Category must equal "F2"3. Value must be 1 character4. Mandatory |
1. Value must be in Claim Denied Indicator List (VVL)2. If value is "0", then Claim Status Category must equal "F2"3. Value must be 1 character4. Mandatory |
| 09/12/2024 |
3.29.0 |
CLT.002.157 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.155 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.153 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.151 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Border State Indicator List (VVL)4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in Border State Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.149 |
UPDATE |
Coding requirement |
1. Value must be numeric2. Value must be 5 digits or less3. Conditional4. When populated, value must be less than or equal to the number of days between (ending date of service minus beginning date of service) plus one day5. (nursing facility) value is required when the Type of Service in [009, 045, 047, 059]6. When populated, if value is greater than zero, then Level of Care Status (ELG.005.088) for the associated MSIS Identification Number (CLT.002.022) must equal '003' (Nursing Facility) for the same month as the begin and end date of service |
1. Value must be numeric2. Value must be 5 digits or less3. Conditional4. When populated, value must be less than or equal to the number of days between (ending date of service minus beginning date of service) plus one day5. (nursing facility) value is required when the Type of Service in [009,045,047,059]6. When populated, if value is greater than zero, then Level of Care Status (ELG.005.088) for the associated MSIS Identification Number (CLT.002.022) must equal "003" (Nursing Facility) for the same month as the begin and end date of service |
| 09/12/2024 |
3.29.0 |
CLT.002.148 |
UPDATE |
Coding requirement |
1. Value must be numeric2. Value must be 5 digits or less3. Conditional4. (Intermediate Care Facility for Individuals with Intellectual Disabilities) value is required when Type of Service (CLT.003.211) in [009, 045, 046, 047, 059] |
1. Value must be numeric2. Value must be 5 digits or less3. Conditional4. (Intermediate Care Facility for Individuals with Intellectual Disabilities) value is required when Type of Service (CLT.003.211) in [009,045,046,047,059] |
| 09/12/2024 |
3.29.0 |
CLT.002.147 |
UPDATE |
Coding requirement |
1. Value must be 5 digits or less2. Conditional3. Value is mandatory when associated Type of Service (CLT.003.211) = '046'4. Value must be less than or equal to the number of days between (ending date of service minus beginning date of service) plus one day5. When populated, if value is greater than 0 and less than 99998, then Level of Care Status (ELG.005.088) for the associated MSIS Identification Number (CLT.002.022) must equal '004' (ICF/IID) for the same month as the begin and end date of service |
1. Value must be 5 digits or less2. Conditional3. Value is mandatory when associated Type of Service (CLT.003.211) equals "046"4. Value must be less than or equal to the number of days between (ending date of service minus beginning date of service) plus one day5. When populated, if value is greater than 0 and less than 99998, then Level of Care Status (ELG.005.088) for the associated MSIS Identification Number (CLT.002.022) must equal '004' (ICF/IID) for the same month as the begin and end date of service |
| 09/12/2024 |
3.29.0 |
CLT.002.145 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.141 |
UPDATE |
Coding requirement |
1. Value must be in Patient Status List (VVL).2. Value must be 2 characters3. Mandatory |
1. Value must be in Patient Status List (VVL)2. Value must be 2 characters3. Mandatory |
| 09/12/2024 |
3.29.0 |
CLT.002.140 |
UPDATE |
Coding requirement |
1. Conditional2. Value must be 12 characters or less3. Value must not contain a pipe or asterisk symbols4. (Not Dual Eligible) if Dual Eligible Code (ELG.DE.085) value = "00", then value must not be populated.5. Value must be populated when Crossover Indicator (CLT.002.023) equals '1' and Medicare Beneficiary Identifier (CLT.002.168) is not populated. |
1. Conditional2. Value must be 12 characters or less3. Value must not contain a pipe or asterisk symbols4. (Not Dual Eligible) if Dual Eligible Code (ELG.DE.085) value = "00", then value must not be populated5. Value must be populated when Crossover Indicator (CLT.002.023) equals "1" and Medicare Beneficiary Identifier (CLT.002.168) is not populated |
| 09/12/2024 |
3.29.0 |
CLT.002.136 |
UPDATE |
Coding requirement |
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. Conditional |
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. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.134 |
UPDATE |
Coding requirement |
1. Value must be in Provider Specialty List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in Provider Specialty List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.133 |
UPDATE |
Coding requirement |
1. Value must be in Provider Type Code List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in Provider Type Code List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.131 |
UPDATE |
Coding requirement |
1. Value must be 10 digits 2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to '2' 3. Value must exist in the NPPES NPI data file 4. Conditional 5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal '01' 6. When Type of Claim is in ['1','3','A','C'], then value must be populated 7. When Type of Claim not in ('3','C','W'), then value must match Provider Identifier (PRV.002.081) 8. NPPES Entity Type Code associated with this NPI must equal ‘2’ (Organization) |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to "2"3. Value must exist in the NPPES NPI data file4. Conditional5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal "01"6. When Type of Claim is in [1,3,A,C], then value must be populated7. When Type of Claim not in [3,C,W], then value must match Provider Identifier (PRV.002.081)8. NPPES Entity Type Code associated with this NPI must equal "2" (Organization) |
| 09/12/2024 |
3.29.0 |
CLT.002.130 |
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.002.019) Submitting State Provider ID or4. 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 where the Provider Identifier5. Ending Date of Service (CLT.002.049) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or6. Ending Date of Service (CLT.002.049) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080)7. Ending Date of Service (CLT.002.049) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or8. Ending Date of Service (CLT.002.049) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) |
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.002.019) Submitting State Provider ID or4. 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 where the Provider Identifier Type (PRV.005.007) equal to "2"5. Ending Date of Service (CLT.002.049) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or6. Ending Date of Service (CLT.002.049) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080)7. Ending Date of Service (CLT.002.049) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or8. Ending Date of Service (CLT.002.049) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) |
| 09/12/2024 |
3.29.0 |
CLT.002.129 |
UPDATE |
Coding requirement |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by a version number [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Conditional |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be "01" or in [21-30](1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20,32,33]6. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.127 |
UPDATE |
Coding requirement |
1. Value must be in Health Home Provider Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If there is an associated Health Home Entity Name value, then value must be "1"5. Conditional |
1. Value must be in Health Home Provider Indicator List (VVL)2. Value must be 1 character3. Value must be in [0,1] or not populated4. If there is an associated Health Home Entity Name value, then value must be "1"5. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.122 |
UPDATE |
Coding requirement |
1. Value must be 20 characters or less2. Value must not contain a pipe or asterisk symbol3. Conditional |
1. Value must be 20 characters or less2. Value must not contain a pipe or asterisk symbols3. Conditional |
| 02/27/2025 |
3.34.0 |
CLT.002.101 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
| 02/27/2025 |
3.34.0 |
CLT.002.100 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
| 02/27/2025 |
3.34.0 |
CLT.002.099 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
| 02/27/2025 |
3.34.0 |
CLT.002.098 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
| 02/27/2025 |
3.34.0 |
CLT.002.097 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
| 02/27/2025 |
3.34.0 |
CLT.002.096 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
| 02/27/2025 |
3.34.0 |
CLT.002.095 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
| 02/27/2025 |
3.34.0 |
CLT.002.094 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
| 02/27/2025 |
3.34.0 |
CLT.002.093 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
| 02/27/2025 |
3.34.0 |
CLT.002.092 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
| 09/12/2024 |
3.29.0 |
CLT.002.091 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Healthcare Acquired Condition Indicator List (VVL).4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in Healthcare Acquired Condition Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.090 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Forced 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 Forced Claim Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.085 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.083 |
UPDATE |
Coding requirement |
1. Value must be in Medicare Reimbursement Type List (VVL)2. Value is mandatory and must be provided, when Crossover Indicator is equal to '1' (Crossover Claim)3. Value must be 2 characters4. Conditional |
1. Value must be in Medicare Reimbursement Type List (VVL)2. Value is mandatory and must be provided, when Crossover Indicator is equal to "1" (Crossover Claim)3. Value must be 2 characters4. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.082 |
UPDATE |
Definition |
The field denotes whether the payment amount was determined at the claim header or line/detail level.For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines’ associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only.For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header.For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed.For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
The field denotes whether the payment amount was determined at the claim header or line/detail level.
For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines’ associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only.
For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header.
For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed.
For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
| 09/12/2024 |
3.29.0 |
CLT.002.080 |
UPDATE |
Coding requirement |
1. Value must be 12 characters or less2. Value must not contain a pipe or asterisk symbols3. Conditional4. Value must match Managed Care Plan ID (ELG.014.192)5. Value must match State Plan ID Number (MCR.002.019)6. Value should not be populated when Type of Claim is not equal to '3', 'C' or 'W'7. When Type of Claim in (3, C, W, 2, B, V) value must have a managed care enrollment (ELG.014) for the beneficiary where the Beginning DOS (CLT.002.048) occurs between the managed care plan enrollment eff/end dates (ELG.014.197/198)8. When Type of Claim in (3, C, W, 2, B, V) value must have a managed care main record (MCR.002) for the plan where the Beginning DOS (CLT.002.048) occurs between the managed care contract eff/end dates (MCR.002.020/021) |
1. Value must be 12 characters or less2. Value must not contain a pipe or asterisk symbols3. Conditional4. Value must match Managed Care Plan ID (ELG.014.192)5. Value must match State Plan ID Number (MCR.002.019)6. Value should not be populated when Type of Claim is in [3,C,W]7. When Type of Claim in [3,C,W,2,B,V] value must have a managed care enrollment (ELG.014) for the beneficiary where the Beginning DOS (CLT.002.048) occurs between the managed care plan enrollment eff/end dates (ELG.014.197/198)8. When Type of Claim in [3,C,W,2,B,V] value must have a managed care main record (MCR.002) for the plan where the Beginning DOS (CLT.002.048) occurs between the managed care contract eff/end dates (MCR.002.020/021) |
| 09/12/2024 |
3.29.0 |
CLT.002.079 |
UPDATE |
Coding requirement |
1. Value must be in Program Type List (VVL)2. Value must be 2 characters3. Mandatory4. (Community First Choice) If value equals '11', then State Plan Option Type (ELG.011.163) must equal '01' for the same time period5. If value equals '13', then State Plan Option Type (ELG.011.163) must equal '02' for the same time period |
1. Value must be in Program Type List (VVL)2. Value must be 2 characters3. Mandatory4. (Community First Choice) If value equals "11", then State Plan Option Type (ELG.011.163) must equal "01" for the same time period5. If value equals '13', then State Plan Option Type (ELG.011.163) must equal '02' for the same time period |
| 09/12/2024 |
3.29.0 |
CLT.002.078 |
UPDATE |
Coding requirement |
1. Value must be in Medicare Combined Deductible Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If value equals '1', then Total Medicare Coinsurance amount must not be populated.5. If value equals '0', then Crossover Indicator must equals '0'6. If value equals '1', then Crossover Indicator must equals '1'7. Conditional |
1. Value must be in Medicare Combined Deductible Indicator List (VVL)2. Value must be 1 character3. Value must be in [0,1] or not populated4. If value equals "1", then Total Medicare Coinsurance amount must not be populated5. If value equals "0", then Crossover Indicator must equals "0"6. If value equals "1", then Crossover Indicator must equals "1"7. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.077 |
UPDATE |
Coding requirement |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Value must be populated if TYPE-OF-CLAIM <> ‘3', ‘C’, ‘W’, or '6’4. Conditional |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Value must be populated if TYPE-OF-CLAIM is not in [3,C,W,6]4. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.076 |
UPDATE |
Coding requirement |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Value must be populated if TYPE-OF-CLAIM <> ‘3', ‘C’, ‘W’, or '6’4. Conditional |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Value must be populated if TYPE-OF-CLAIM is not in [3,C,W,6]4. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.075 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Fixed Payment Indicator List (VVL)4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in Fixed Payment Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.074 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Type of Claim value is in [4, D, or X], then value is mandatory and must be provided4. Conditional5. When populated, Service Tracking Type must be populated6. When populated, Total Medicaid Amount must not be populated |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. If associated Type of Claim value is in [4,D,X], then value is mandatory and must be provided4. Conditional5. When populated, Service Tracking Type must be populated6. When populated, Total Medicaid Amount must not be populated |
| 09/12/2024 |
3.29.0 |
CLT.002.073 |
UPDATE |
Coding requirement |
1. Value must be in Service Tracking Type List (VVL)2. (Service Tracking Claim) if associated Type of Claim is in ['4','D', 'X'] then value is mandatory and must be reported3. Value must be 2 characters4. Conditional |
1. Value must be in Service Tracking Type List (VVL)2. (Service Tracking Claim) if associated Type of Claim is in [4,D,X] then value is mandatory and must be reported3. Value must be 2 characters4. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.071 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Other Insurance Indicator List (VVL)4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in Other Insurance Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.070 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.069 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than associated Total Billed Amount - (Total Medicare Coinsurance Amount + Total Medicare Deductible Amount)4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Value must be less than associated Total Billed Amount - (Total Medicare Coinsurance Amount + Total Medicare Deductible Amount)4. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.068 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated.4. Conditional5. If associated Medicare Combined Deductible Indicator is '1', then value must not be populated6. When populated, value must be less than or equal to Total Billed Amount |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. If associated Crossover Indicator value is "0" (not a crossover claim), then value should not be populated4. Conditional5. If associated Medicare Combined Deductible Indicator is "1", then value must not be populated6. When populated, value must be less than or equal to Total Billed Amount |
| 09/12/2024 |
3.29.0 |
CLT.002.067 |
UPDATE |
Definition |
The amount paid by Medicaid/CHIP, on this claim at the claim header level, toward the beneficiary's Medicare deductible. If the Medicare deductible amount can be identified separately from Medicare coinsurance payments, code that amount in this field. If the Medicare coinsurance and deductible payments cannot be separated, fill this field with the combined payment amount, code Medicare Combined Indicator a "1" and leave Total Medicare Coinsurance Amount unpopulated. |
The amount paid by Medicaid/CHIP, on this claim at the claim header level, toward the beneficiary's Medicare deductible. If the Medicare deductible amount can be identified separately from Medicare coinsurance payments, code that amount in this field. If the Medicare coinsurance and deductible payments cannot be separated, fill this field with the combined payment amount, code Medicare Combined Indicator a '1' and leave Total Medicare Coinsurance Amount unpopulated. |
| 09/12/2024 |
3.29.0 |
CLT.002.067 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated.4. Conditional5. When populated, value must be less than or equal to Total Billed Amount |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. If associated Crossover Indicator value is "0" (not a crossover claim), then value should not be populated4. Conditional5. When populated, value must be less than or equal to Total Billed Amount |
| 09/12/2024 |
3.29.0 |
CLT.002.065 |
UPDATE |
Definition |
The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider.
For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 09/12/2024 |
3.29.0 |
CLT.002.065 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must not be greater than Total Allowed Amount8. Value must be populated, when Type of Claim is in [‘1’, ‘A’]9. Value must not be populated or equal to ‘0.00’ when associated Claim Status is in ['26', '026', '87', '087', '542', '585', '654']10. Value should not be populated, when associated Type of Claim value is in [‘4’, ‘D’] 11. Value must be less than Total Allowed Amount11. Value must be populated when the associated Type of Claim (CLT.002.052) is in [‘5’, ‘E’] |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals "2", value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must not be greater than Total Allowed Amount8. Value must be populated, when Type of Claim is in [1,A]9. Value must not be populated or equal to "0.00" when associated Claim Status is in [26,026,87,087,542,585,654]10. Value should not be populated, when associated Type of Claim value is in [4,D]11. Value must be less than Total Allowed Amount12. Value must be populated when the associated Type of Claim (CLT.002.052) is in [5,E] |
| 09/12/2024 |
3.29.0 |
CLT.002.064 |
UPDATE |
Definition |
The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. On managed care encounters the Allowed Amount is determined by the managed care organization.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity allowed for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
The claim header level maximum amount determined by the payer as being "allowable" under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state"s MMIS. On managed care encounters the Allowed Amount is determined by the managed care organization.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity allowed for the service. Report a null value in this field if the provider is a sub-capitated network provider.
For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 09/12/2024 |
3.29.0 |
CLT.002.064 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. When populated and Payment Level Indicator = '2' then value must equal the sum of all claim line Allowed Amount values4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. When populated and Payment Level Indicator equals "2" then value must equal the sum of all claim line Allowed Amount values4. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.063 |
UPDATE |
Definition |
The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. Report a null value in this field if the provider is a sub-capitated network provider.
For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 09/12/2024 |
3.29.0 |
CLT.002.063 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must equal the sum of all Billed Amount instances for the associated claim4. Conditional5. When associated Type of Claim in [‘1’, ’3’, ’A’, ’C’], value must be populated 6. Value should not be populated when associated Type of Claim (CLT.002.052) is equal to '4', 'D' or 'X'7. (individual line item payments) when populated and Payment Level Indicator (CLT.002.082) equals = '2' value must be greater than or equal to the sum of all claim line Revenue Charges (CLT.003.204) |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Value must equal the sum of all Billed Amount instances for the associated claim4. Conditional5. When associated Type of Claim in [1,3,A,C] and Source Location does not equal "23", value must be populated6. Value should not be populated when associated Type of Claim (CLT.002.052) is in [4,D,X]7. (individual line item payments) when populated and Payment Level Indicator (CLT.002.082) equals "2" value must be greater than or equal to the sum of all claim line Revenue Charges (CLT.003.204) |
| 09/12/2024 |
3.29.0 |
CLT.002.056 |
UPDATE |
Definition |
The field denotes the claims payment system from which the claim was extracted.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = '22' to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis.For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = '23' to indicate that the sub-capitated network provider provided the service directly to the enrollee.For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = “23” to indicate that the sub-capitated network provider provided the service directly to the enrollee. |
The field denotes the claims payment system from which the claim was extracted.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = "22" to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis.
For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = "23" to indicate that the sub-capitated network provider provided the service directly to the enrollee.
For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = “23” to indicate that the sub-capitated network provider provided the service directly to the enrollee. |
| 09/12/2024 |
3.29.0 |
CLT.002.055 |
UPDATE |
Coding requirement |
1. Value must be in Claim Status Category List (VVL)2. (Denied Claim) if associated Claim Denied Indicator indicates the claim was denied, then value must be "F2"3. (Denied Claim) if associated Claim Status is in [ 542, 585, 654 ], then value must be "F2"4. Value must be 3 characters or less5. Mandatory |
1. Value must be in Claim Status Category List (VVL)2. (Denied Claim) if associated Claim Denied Indicator indicates the claim was denied, then value must be "F2"3. (Denied Claim) if associated Claim Status is in [542,585,654], then value must be "F2"4. Value must be 3 characters or less5. Mandatory |
| 09/12/2024 |
3.29.0 |
CLT.002.054 |
UPDATE |
Coding requirement |
1. Value must be in Claim Status List (VVL)2. Value must be 3 characters or less3. Conditional4. If value in [ 542, 585, 654 ], Claim Denied Indicator must be '0' and Claim Status Category must be 'F2' |
1. Value must be in Claim Status List (VVL)2. Value must be 3 characters or less3. Conditional4. If value in [542,585,654], Claim Denied Indicator must be "0" and Claim Status Category must be "F2" |
| 09/12/2024 |
3.29.0 |
CLT.002.053 |
UPDATE |
Coding requirement |
1. Value must be in Type of Bill List (VVL)2. Value must be 4 characters3. First character must be a '0'4. Mandatory |
1. Value must be in Type of Bill List (VVL)2. Value must be 4 characters3. First character must be a "0"4. Mandatory |
| 09/12/2024 |
3.29.0 |
CLT.002.052 |
UPDATE |
Definition |
A code to indicate what type of payment is covered in this claim.For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record. |
A code to indicate what type of payment is covered in this claim.
For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = "3" for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record. |
| 09/12/2024 |
3.29.0 |
CLT.002.052 |
UPDATE |
Coding requirement |
1. Value must be in Type of Claim List (VVL)2. Value must be 1 character3. Mandatory4. When value equals 'Z', claim denied indicator must equal '0' |
1. Value must be in Type of Claim List (VVL)2. Value must be 1 character3. Mandatory4. When value equals 'Z', claim denied indicator must equal "0" |
| 09/12/2024 |
3.29.0 |
CLT.002.049 |
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 |
CLT.002.048 |
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 |
| 09/12/2024 |
3.29.0 |
CLT.002.046 |
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. Value must be less than or equal to associated Adjudication Date value.4. Value must be greater than or equal to associated Admission Date value.5. Value must be greater than or equal to associated eligible Date of Birth value.6. Value must be less than or equal to associated eligible Date of Death value.7. Conditional8. When populated, Discharge Hour (CLT.002.047) must be populated |
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. Value must be less than or equal to associated Adjudication Date value4. Value must be greater than or equal to associated Admission Date value5. Value must be greater than or equal to associated eligible Date of Birth value6. Value must be less than or equal to associated eligible Date of Death value7. Conditional8. When populated, Discharge Hour (CLT.002.047) must be populated |
| 09/12/2024 |
3.29.0 |
CLT.002.044 |
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. Value must be less than or equal to associated Discharge Date value in the claim header.4. Value must be greater than or equal to associated eligible Date of Birth value.5. Value must be less than or equal to associated eligible Date of Death value.6. Mandatory7. When associated Type of Claim (CLT.002.052) is not '2','B' or 'V' (capitated payment) value must be before Adjudication Date (CLT.002.050)8. When associated Type of Claim (CLT.002.052) is not '2','B' or 'V' (capitated payment) and Type of Service (CLT.003.211) is not '119, '120', '121', 122' value must be before Adjudication Date (CLT.003.233) |
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. Value must be less than or equal to associated Discharge Date value in the claim header4. Value must be greater than or equal to associated eligible Date of Birth value5. Value must be less than or equal to associated eligible Date of Death value6. Mandatory7. When associated Type of Claim (CLT.002.052) is not in [2,B,V] (capitated payment) value must be before Adjudication Date (CLT.002.050)8. When associated Type of Claim (CLT.002.052) is not [2,B,V] (capitated payment) and Type of Service (CLT.003.211) is not [119,120,121,122] value must be before Adjudication Date (CLT.003.233) |
| 09/12/2024 |
3.29.0 |
CLT.002.024 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Conditional5. When value equals '0', is invalid or not populated, the associated 1115A Demonstration Indicator (ELG.018.233) must equal '0', is invalid or not populated |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Conditional5. When value equals "0", is invalid or not populated, the associated 1115A Demonstration Indicator (ELG.018.233) must equal "0", is invalid or not populated |
| 09/12/2024 |
3.29.0 |
CLT.002.023 |
UPDATE |
Coding requirement |
1. Value must be in Crossover Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service)5. If the Type of Claim value is in ["1", "3", "A", "C"], then value is mandatory and must be reported.6. Conditional |
1. Value must be in Crossover Indicator List (VVL)2. Value must be 1 character3. Value must be in [0,1] or not populated4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in [01,02,04,08,09,10] for the same time period (by date of service)5. If the Type of Claim value is in [1,3,A,C], then value is mandatory and must be reported6. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.022 |
UPDATE |
Coding requirement |
1. Mandatory2. Value must be 20 characters or less3. Populated value must begin with an '&', when TYPE-OF-CLAIM = 4, D or X (lump sum payment)4. The Beginning Date of Service on the claim must fall between (ELG.021.253) enrollment effective and (ELG.021.253) end date |
1. Mandatory2. Value must be 20 characters or less3. When TYPE-OF-CLAIM is in [4,D,X] (lump sum payment), value must begin with an "&"4. The Beginning Date of Service on the claim must fall between (ELG.021.253) enrollment effective and (ELG.021.253) end date |
| 09/12/2024 |
3.29.0 |
CLT.002.020 |
UPDATE |
Coding requirement |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [‘4’, ‘1’] then value must be populated |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is "0", then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [4,1], then value must be populated |
| 09/12/2024 |
3.29.0 |
CLT.001.011 |
UPDATE |
Coding requirement |
1. For production files, value must be equal to 'P'2. Value must be in File Status Indicator List (VVL)3. Value must be 1 character4. Mandatory |
1. For production files, value must be equal to "P"2. Value must be in File Status Indicator List (VVL)3. Value must be 1 character4. Mandatory |
| 09/12/2024 |
3.29.0 |
CLT.001.006 |
UPDATE |
Coding requirement |
1. Value must equal 'CLAIM-LT'2. Mandatory |
1. Value must equal "CLAIM-LT"2. Mandatory |
| 09/12/2024 |
3.29.0 |
CIP.003.296 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1]3. Mandatory |
1. Value must be 1 character2. Value must be in [0,1]3. Mandatory |
| 09/12/2024 |
3.29.0 |
CIP.003.285 |
UPDATE |
Coding requirement |
1. Value must be in NDC Unit of Measure List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in NDC Unit of Measure List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.003.272 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.003.271 |
UPDATE |
Coding requirement |
1. Value must be in XXI MBESCBES Category of Service List (VVL)2. Conditional3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is '02', then a valid value is mandatory and must be reported4. If XIX MBESCBES Category of Service is populated then value must not be populated5. Value must be 3 characters or less |
1. Value must be in XXI MBESCBES Category of Service List (VVL)2. Conditional3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is "02", then a valid value is mandatory and must be reported4. If XIX MBESCBES Category of Service is populated then value must not be populated5. Value must be 3 characters or less |
| 09/12/2024 |
3.29.0 |
CIP.003.270 |
UPDATE |
Coding requirement |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is '01', then a valid value is mandatory and must be reported5. If value is in ['14', '35', '42' or '44'], then Sex (ELG.002.023) must not equals 'M'6. If XXI MBESCBES Category of Service is populated then must not be populated |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is "01", then a valid value is mandatory and must be reported5. If value is in [14,35,42,44], then Sex (ELG.002.023) must not equal "M"6. If XXI MBESCBES Category of Service is populated then must not be populated |
| 09/12/2024 |
3.29.0 |
CIP.003.269 |
UPDATE |
Coding requirement |
1. Value must be in CMS 64 Category for Federal Reimbursement List (VVL)2. Value must be 2 characters3. (Federal Funding under Title XXI) if value equals '02', then the eligible's CHIP Code (ELG.003.054) must be in ['2', '3']4. (Federal Funding under Title XIX) if value equals '01' then the eligible's CHIP Code (ELG.003.054) must be '1'5. Conditional6. If Type of Claim is in ['1','2','5','A','B','E','U','V','Y'] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported7. If Type of Claim is in ['4','D'] and the Service Tracking Payment Amount on the relevant record is populated, then value must be reported8. When Type of Claim is in [‘1’,‘A’], value must be populated |
1. Value must be in CMS 64 Category for Federal Reimbursement List (VVL)2. Value must be 2 characters3. (Federal Funding under Title XXI) if value equals "02", then the eligible's CHIP Code (ELG.003.054) must be in [2,3]4. (Federal Funding under Title XIX) if value equals "01" then the eligible's CHIP Code (ELG.003.054) must be "1"5. Conditional6. If Type of Claim is in [1,2,5,A,B,E,U,V,Y] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported7. If Type of Claim is in [4,D] and the Service Tracking Payment Amount on the relevant record is populated, then value must be reported8. When Type of Claim is in [1,A], value must be populated |
| 09/12/2024 |
3.29.0 |
CIP.003.264 |
UPDATE |
Coding requirement |
1. Value must be in Provider Specialty List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in Provider Specialty List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.003.263 |
UPDATE |
Coding requirement |
1. Value must be in Provider Type Code List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in Provider Type Code List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.003.257 |
UPDATE |
Coding requirement |
1. Value must be 3 characters2. Mandatory3. Value must not equal '086' if Sex (ELG.002.023) equals 'M'4. Value must be in ['001', '058', '060', '084', '086', '090', '091', '092', '093', '123', '132', '135', '136', '137'] |
1. Value must be 3 characters2. Mandatory3. Value must not equal "086" if Sex (ELG.002.023) equals "M"4. Value must be in [001,058,060,084,086,090,091,092,093,123,132,135,136,137] |
| 09/12/2024 |
3.29.0 |
CIP.003.256 |
UPDATE |
Coding requirement |
1. Value must be in Billing Unit List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in Billing Unit List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.003.255 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Type of Claim value equals '3, C, W', then value is mandatory and must be provided4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. If associated Type of Claim value is in [3,C,W], then value is mandatory and must be provided4. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.003.254 |
UPDATE |
Definition |
The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.
For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 09/12/2024 |
3.29.0 |
CIP.003.254 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional4. Value should not be populated or equal to zero, when associated Claim Line Status is in ['26', '026', '87', '087', '542', '585', '654'] |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional4. Value should not be populated or equal to zero, when associated Claim Line Status is in [26,026,87,087,542,585,654] |
| 09/12/2024 |
3.29.0 |
CIP.003.252 |
UPDATE |
Definition |
The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed care encounters the Allowed Amount is determined by the managed care organization.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity allowed at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
The maximum amount displayed at the claim line level as determined by the payer as being "allowable" under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state"s MMIS (or PBM). On managed care encounters the Allowed Amount is determined by the managed care organization.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity allowed at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.
For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 09/12/2024 |
3.29.0 |
CIP.003.252 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.003.251 |
UPDATE |
Definition |
The total amount billed for the related Revenue Code. Total amount billed includes both covered and non-covered charges (as defined by UB-04 Billing Manual). For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed to the managed care plan.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the provider billed the sub-capitated entity at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
The total amount billed for the related Revenue Code. Total amount billed includes both covered and non-covered charges (as defined by UB-04 Billing Manual). For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed to the managed care plan.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the provider billed the sub-capitated entity at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.
For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 09/12/2024 |
3.29.0 |
CIP.003.251 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than or equal to associated Total Billed Amount value4. When populated, associated claim line Revenue Charge must be populated5. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Value must be less than or equal to associated Total Billed Amount value4. When populated and the Source Location does not equal “23”, the associated claim line Revenue Code must be populated5. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.003.245 |
UPDATE |
Coding requirement |
1. Value must be in Revenue Code List (VVL)2. A Revenue Code value requires an associated Revenue Charge3. Value must be 4 characters or less4. Mandatory |
1. Value must be in Revenue Code List (VVL)2. When Source Location does not equal “23”, value requires an associated Revenue Charge3. Value must be 4 characters or less4. Mandatory |
| 09/12/2024 |
3.29.0 |
CIP.003.244 |
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.003.243 |
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 |
| 09/12/2024 |
3.29.0 |
CIP.003.242 |
UPDATE |
Coding requirement |
1. Value must be in Claim Status List (VVL)2. Value must be 3 characters or less3. Conditional4. If value in [545, 585, 654], then Claim Denied Indicator must be '0' and Claim Status Category must be 'F2' |
1. Value must be in Claim Status List (VVL)2. Value must be 3 characters or less3. Conditional4. If value in [545,585,654], then Claim Denied Indicator must be "0" and Claim Status Category must be "F2" |
| 09/12/2024 |
3.29.0 |
CIP.003.239 |
UPDATE |
Coding requirement |
1. Value must be in Line 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. Conditional6. If associated Line Adjustment Number is populated, then value must be populated |
1. Value must be in Line 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. Conditional6. If associated Line Adjustment Number is populated, then value must be populated |
| 09/12/2024 |
3.29.0 |
CIP.003.236 |
UPDATE |
Coding requirement |
Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [‘4’, ‘1’] then value must be populated |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is "0", then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [4,1] then value must be populated |
| 09/12/2024 |
3.29.0 |
CIP.003.234 |
UPDATE |
Coding requirement |
1. Mandatory2. Value must be 20 characters or less3. When Type of Claim (CIP.002.100) = 4, D or X (lump sum payment) value must begin with an '&' |
1. Mandatory2. Value must be 20 characters or less3. When Type of Claim (CIP.002.100) is in [4,D,X] (lump sum payment) value must begin with an "&" |
| 09/12/2024 |
3.29.0 |
CIP.002.295 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.294 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.293 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.292 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.228 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is "0", then the value must not be populated.4. Conditional5. If value is populated, Crossover Indicator must be equal to "1" |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. If associated Crossover Indicator value is "0", then the value must not be populated4. Conditional5. If value is populated, Crossover Indicator must be equal to "1" |
| 09/12/2024 |
3.29.0 |
CIP.002.222 |
UPDATE |
Coding requirement |
1. Conditional2. Value must be an 11-character string3. Character 1 must be numeric values 1 thru 94. Character 2 must be alphabetic values A thru Z (minus S, L, O, I, B, Z)5. Character 3 must be alphanumeric values 0 thru 9 or A thru Z (minus S, L, O, I, B, Z)6. Character 4 must be numeric values 0 thru 97. Character 5 must be alphabetic values A thru Z (minus S, L, O, I, B, Z)8. Character 6 must be alphanumeric values 0 thru 9 or A thru Z (minus S, L, O, I, B, Z)9. Character 7 must be numeric values 0 thru 910. Character 8 must be alphabetic values A thru Z (minus S, L, O, I, B, Z)11. Character 9 must be alphabetic values A thru Z (minus S, L, O, I, B, Z)12. Character 10 must be numeric values 0 thru 913. Character 11 must be numeric values 0 thru 914. Value must not contain a pipe or asterisk symbols |
1. Conditional2. Value must be an 11-character string3. Character 1 must be numeric values 1 thru 94. Character 2 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)5. Character 3 must be alphanumeric values 0 thru 9 or A thru Z (minus S,L,O,I,B,Z)6. Character 4 must be numeric values 0 thru 97. Character 5 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)8. Character 6 must be alphanumeric values 0 thru 9 or A thru Z (minus S,L,O,I,B,Z)9. Character 7 must be numeric values 0 thru 910. Character 8 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)11. Character 9 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)12. Character 10 must be numeric values 0 thru 913. Character 11 must be numeric values 0 thru 914. Value must not contain a pipe or asterisk symbols |
| 09/12/2024 |
3.29.0 |
CIP.002.221 |
UPDATE |
Coding requirement |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to '2' 3. Value must exist in the NPPES NPI data file4. Conditional |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to "2"3. Value must exist in the NPPES NPI data file4. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.220 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional4. When Type of Claim is in ['4', 'D', 'X'], value must not be populated |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional4. When Type of Claim is in [4,D,X], value must not be populated |
| 09/12/2024 |
3.29.0 |
CIP.002.218 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Situational |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Situational |
| 09/12/2024 |
3.29.0 |
CIP.002.216 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Situational |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Situational |
| 09/12/2024 |
3.29.0 |
CIP.002.214 |
UPDATE |
Definition |
A free-form text field to indicate the health home program that authorized payment for the service on the claim or to identify the health home SPA in which an individual is enrolled. The name entered should be the name that the state uses to uniquely identify the team. A "Health Home Entity" can be a designated provider (e.g., physician, clinic,
behavioral health organization), a health team which links to a designated provider, or a health team (physicians, nurses, behavioral health professionals). Because an identification numbering schema has not been established, the entities' names are being used instead. |
A free-form text field to indicate the health home program that authorized payment for the service on the claim or to identify the health home SPA in which an individual is enrolled. The name entered should be the name that the state uses to uniquely identify the team. A "Health Home Entity" can be a designated provider (e.g., physician, clinic, behavioral health organization), a health team which links to a designated provider, or a health team (physicians, nurses, behavioral health professionals). Because an identification numbering schema has not been established, the entities" names are being used instead. |
| 09/12/2024 |
3.29.0 |
CIP.002.213 |
UPDATE |
Coding requirement |
1. Value must be in Copay Waived Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. Situational |
1. Value must be in Copay Waived Indicator List (VVL)2. Value must be 1 character3. Value must be in [0,1] or not populated4. Situational |
| 09/12/2024 |
3.29.0 |
CIP.002.212 |
UPDATE |
Coding requirement |
1. Value must be in Claim Denied Indicator List (VVL)2. If value is '0', then Claim Status Category must equal "F2"3. Value must be 1 character4. Mandatory |
1. Value must be in Claim Denied Indicator List (VVL)2. If value is "0", then Claim Status Category must equal "F2"3. Value must be 1 character4. Mandatory |
| 09/12/2024 |
3.29.0 |
CIP.002.210 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.208 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.206 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.204 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Border State Indicator List (VVL)4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in Border State Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.199 |
UPDATE |
Coding requirement |
1. Value must be in Patient Status List (VVL).2. Value must be 2 characters3. Mandatory4. When value in ["20", "40", "41", "42"], then associated Discharge Date (CIP.002.096) must be less than or equal to Date of Death (ELG.002.025) |
1. Value must be in Patient Status List (VVL)2. Value must be 2 characters3. Mandatory4. When value in [20,40,41,42], then associated Discharge Date (CIP.002.096) must be less than or equal to Date of Death (ELG.002.025) |
| 09/12/2024 |
3.29.0 |
CIP.002.198 |
UPDATE |
Coding requirement |
1. Value must be numeric2. The value may be up to 5 digits in length3. Value must be populated, if Outlier Code (CIP.002.197) equals '01.'4. Conditional |
1. Value must be numeric2. The value may be up to 5 digits in length3. Value must be populated, if Outlier Code (CIP.002.197) equals "01"4. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.196 |
UPDATE |
Coding requirement |
1. Conditional2. Value must be 12 characters or less3. Value must not contain a pipe or asterisk symbols4. (Not Dual Eligible) if Dual Eligible Code (ELG.DE.085) value = "00", then value must not be populated.5. Value must be populated when Crossover Indicator (CIP.002.023) equals '1' and Medicare Beneficiary Identifier (CIP.002.222) is not populated. |
1. Conditional2. Value must be 12 characters or less3. Value must not contain a pipe or asterisk symbols4. (Not Dual Eligible) if Dual Eligible Code (ELG.DE.085) value equals "00", then value must not be populated5. Value must be populated when Crossover Indicator (CIP.002.023) equals "1" and Medicare Beneficiary Identifier (CIP.002.222) is not populated |
| 09/12/2024 |
3.29.0 |
CIP.002.194 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be populated when Outlier Code (CIP.002.197) is '01' ,'02' or '10'4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Value must be populated when Outlier Code (CIP.002.197) is in [01,02,10]4. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.190 |
UPDATE |
Coding requirement |
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. Conditional |
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. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.188 |
UPDATE |
Coding requirement |
1. Value must be in Provider Type Code List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in Provider Type Code List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.186 |
UPDATE |
Coding requirement |
1. Value must be in Provider Specialty List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in Provider Specialty List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.184 |
UPDATE |
Coding requirement |
1. Value must be 10 digits2. Conditional3. Value must have an associated Provider Identifier Type equal to '2'4. Value must exist in the NPPES NPI File |
1. Value must be 10 digits2. Conditional3. Value must have an associated Provider Identifier Type equal to "2"4. Value must exist in the NPPES NPI File |
| 09/12/2024 |
3.29.0 |
CIP.002.183 |
UPDATE |
Coding requirement |
1. Value must be in Provider Specialty List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in Provider Specialty List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.182 |
UPDATE |
Coding requirement |
1. Value must be in Provider Type Code List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in Provider Type Code List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.180 |
UPDATE |
Coding requirement |
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 populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal '01'6. When Type of Claim is in ['1','3','A','C'], then value must be populated7. NPPES Entity Type Code associated with this NPI must equal ‘2’ (Organization) |
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 populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal "01"6. When Type of Claim is in [1,3,A,C], then value must be populated7. NPPES Entity Type Code associated with this NPI must equal "2" (Organization) |
| 09/12/2024 |
3.29.0 |
CIP.002.179 |
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.002.019) Submitting State Provider ID or4. 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 where the Provider Identifier5. Discharge Date (CIP.002.096) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or6. Discharge Date (CIP.002.096) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080)7. Discharge Date (CIP.002.096) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or8. Discharge Date (CIP.002.096) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) |
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.002.019) Submitting State Provider ID or4. 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 where the Provider Identifier Type (PRV.005.081) equal to "1"5. Discharge Date (CIP.002.096) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or6. Discharge Date (CIP.002.096) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080)7. Discharge Date (CIP.002.096) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or8. Discharge Date (CIP.002.096) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) |
| 09/12/2024 |
3.29.0 |
CIP.002.178 |
UPDATE |
Coding requirement |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by a version number [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Conditional |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30](1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20,32,33]6. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.176 |
UPDATE |
Coding requirement |
1. Value must be in Health Home Provider Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If there is an associated Health Home Entity Name value, then value must be "1"5. Conditional |
1. Value must be in Health Home Provider Indicator List (VVL)2. Value must be 1 character3. Value must be in [0,1] or not populated4. If there is an associated Health Home Entity Name value, then value must be "1"5. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.167 |
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. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. 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. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 02/27/2025 |
3.34.0 |
CIP.002.149 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
| 02/27/2025 |
3.34.0 |
CIP.002.148 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
| 02/27/2025 |
3.34.0 |
CIP.002.147 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
| 02/27/2025 |
3.34.0 |
CIP.002.146 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
| 02/27/2025 |
3.34.0 |
CIP.002.145 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
| 02/27/2025 |
3.34.0 |
CIP.002.144 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
| 02/27/2025 |
3.34.0 |
CIP.002.143 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
| 02/27/2025 |
3.34.0 |
CIP.002.142 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
| 02/27/2025 |
3.34.0 |
CIP.002.141 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
| 02/27/2025 |
3.34.0 |
CIP.002.140 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
| 09/12/2024 |
3.29.0 |
CIP.002.139 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Healthcare Acquired Condition Indicator List (VVL).4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in Healthcare Acquired Condition Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.138 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Forced 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 Forced Claim Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.136 |
UPDATE |
Coding requirement |
1. Value must be a positive integer2. Value must be between 0:99999999999 (inclusive)3. Conditional4. Value must be less than or equal to double the number of days between Admission Date Discharge Date (CIP.002.094) and Discharge Date Discharge Date (CIP.002.096) plus one day5. Value must be 7 digits or less6. Value is required if the associated Type of Service (CIP.002.257) is in [001, 058, 060, 084, 086, 090, 091, 092, 093, 123, 132]7. Value is required if at least one associated Revenue Code (CIP.003.245) is in [100-219] |
1. Value must be a positive integer2. Value must be between 0:99999999999 (inclusive)3. Conditional4. Value must be less than or equal to double the number of days between Admission Date Discharge Date (CIP.002.094) and Discharge Date Discharge Date (CIP.002.096) plus one day5. Value must be 7 digits or less6. Value is required if the associated Type of Service (CIP.002.257) is in [001,058,060,084,086,090,091,092,093,123,132]7. Value is required if at least one associated Revenue Code (CIP.003.245) is in [100-219] |
| 09/12/2024 |
3.29.0 |
CIP.002.135 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.133 |
UPDATE |
Coding requirement |
1. Value must be in Medicare Reimbursement Type List (VVL)2. Value is mandatory and must be provided, when Crossover Indicator is equal to '1' (Crossover Claim)3. Value must be 2 characters4. Conditional |
1. Value must be in Medicare Reimbursement Type List (VVL)2. Value is mandatory and must be provided, when Crossover Indicator is equal to "1" (Crossover Claim)3. Value must be 2 characters4. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.132 |
UPDATE |
Definition |
The field denotes whether the payment amount was determined at the claim header or line/detail level.For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines’ associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only.For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header.For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed.For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
The field denotes whether the payment amount was determined at the claim header or line/detail level.
For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines’ associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only.
For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header.
For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed.
For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
| 09/12/2024 |
3.29.0 |
CIP.002.130 |
UPDATE |
Coding requirement |
1. Value must be 12 characters or less2. Value must not contain a pipe or asterisk symbols3. Conditional4. Value must match Managed Care Plan ID (ELG.014.192)5. Value must match State Plan ID Number (MCR.002.019)6. When Type of Claim (CIP.002.100) in (3, C, W, 2, B, V) value must have a managed care enrollment (ELG.014) for the beneficiary where the Admission Date (CIP.002.094) occurs between the managed care plan enrollment eff/end dates (ELG.014.197/198)7. When Type of Claim (CIP.002.100) in (3, C, W, 2, B, V) value must have a managed care main record (MCR.002) for the plan where the Admission Date (CIP.002.094) occurs between the managed care contract eff/end dates (MCR.002.020/021) |
1. Value must be 12 characters or less2. Value must not contain a pipe or asterisk symbols3. Conditional4. Value must match Managed Care Plan ID (ELG.014.192)5. Value must match State Plan ID Number (MCR.002.019)6. When Type of Claim (CIP.002.100) in (3,C,W,2,B,V) value must have a managed care enrollment (ELG.014) for the beneficiary where the Admission Date (CIP.002.094) occurs between the managed care plan enrollment eff/end dates (ELG.014.197/198)7. When Type of Claim (CIP.002.100) in (3,C,W,2,B,V) value must have a managed care main record (MCR.002) for the plan where the Admission Date (CIP.002.094) occurs between the managed care contract eff/end dates (MCR.002.020/021) |
| 09/12/2024 |
3.29.0 |
CIP.002.129 |
UPDATE |
Coding requirement |
1. Value must be in Program Type List (VVL)2. Value must be 2 characters3. Mandatory4. (Community First Choice) If value equals '11', then State Plan Option Type (ELG.011.163) must equal '01' for the same time period5. If value equals '13', then State Plan Option Type (ELG.011.163) must equal '02' for the same time period |
1. Value must be in Program Type List (VVL)2. Value must be 2 characters3. Mandatory4. (Community First Choice) If value equals "11", then State Plan Option Type (ELG.011.163) must equal "01" for the same time period5. If value equals "13", then State Plan Option Type (ELG.011.163) must equal "02" for the same time period |
| 09/12/2024 |
3.29.0 |
CIP.002.128 |
UPDATE |
Coding requirement |
1. Value must be in Medicare Combined Deductible Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If value equals '1', then Total Medicare Coinsurance amount must not be populated.5. If value equals '0', then Crossover Indicator must equals '0'6. If value equals '1', then Crossover Indicator must equals '1'7. Conditional |
1. Value must be in Medicare Combined Deductible Indicator List (VVL)2. Value must be 1 character3. Value must be in [0,1] or not populated4. If value equals "1", then Total Medicare Coinsurance amount must not be populated5. If value equals "0", then Crossover Indicator must equals "0"6. If value equals "1", then Crossover Indicator must equals "1"7. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.127 |
UPDATE |
Coding requirement |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Value must be populated if TYPE-OF-CLAIM <> ‘3', ‘C’, ‘W’, or '6’4. Conditional |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Value must be populated if Type of Claim is not equal to [3,C,W,6]4. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.126 |
UPDATE |
Coding requirement |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Value must be populated if TYPE-OF-CLAIM <> ‘3', ‘C’, ‘W’, or '6’4. Conditional |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Value must be populated if Type of Claim is not equal to [3,C,W,6]4. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.125 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Fixed Payment Indicator List (VVL)4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in Fixed Payment Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.124 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Type of Claim value is in [4, D, or X], then value is mandatory and must be provided4. Conditional5. When populated, Service Tracking Type must be populated6. When populated, Total Medicaid Amount must not be populated |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. If associated Type of Claim value is in [4,D,X], then value is mandatory and must be provided4. Conditional5. When populated, Service Tracking Type must be populated6. When populated, Total Medicaid Amount must not be populated |
| 09/12/2024 |
3.29.0 |
CIP.002.123 |
UPDATE |
Coding requirement |
1. Value must be in Service Tracking Type List (VVL)2. (Service Tracking Claim) if associated Type of Claim is in ['4','D', 'X'] then value is mandatory and must be reported3. Value must be 2 characters4. Conditional |
1. Value must be in Service Tracking Type List (VVL)2. (Service Tracking Claim) if associated Type of Claim is in [4,D,X] then value is mandatory and must be reported3. Value must be 2 characters4. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.121 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Other Insurance Indicator List (VVL)4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in Other Insurance Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.119 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.118 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than associated Total Billed Amount - (Total Medicare Coinsurance Amount + Total Medicare Deductible Amount)4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Value must be less than associated Total Billed Amount - (Total Medicare Coinsurance Amount + Total Medicare Deductible Amount)4. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.117 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated.4. Conditional5. If associated Medicare Combined Deductible Indicator is '1', then value must not be populated6. When populated, value must be less than or equal to Total Billed Amount |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. If associated Crossover Indicator value is "0" (not a crossover claim), then value should not be populated4. Conditional5. If associated Medicare Combined Deductible Indicator is "1", then value must not be populated6. When populated, value must be less than or equal to Total Billed Amount |
| 09/12/2024 |
3.29.0 |
CIP.002.116 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated.4. (Medicare Enrolled) if associated Dual Eligible Code (ELG.005.085) value is in ["01", "02", "03", "04", "05", "06", "08", "09", or "10"], then value is mandatory and must be provided5. Conditional6. When populated, value must be less than or equal to Total Billed Amount |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. If associated Crossover Indicator value is "0" (not a crossover claim), then value should not be populated4. (Medicare Enrolled) if associated Dual Eligible Code (ELG.005.085) value is in [01,02,03,04,05,06,08,09,10], then value is mandatory and must be provided5. Conditional6. When populated, value must be less than or equal to Total Billed Amount |
| 09/12/2024 |
3.29.0 |
CIP.002.114 |
UPDATE |
Definition |
The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider.
For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field.
|
| 09/12/2024 |
3.29.0 |
CIP.002.114 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must be populated, when Type of Claim is in [‘1’, ‘A’]8. Value must not be populated or equal to ‘0.00’ when associated Claim Status is in ['26', '026', '87', '087', '542', '585', '654']9. Value should not be populated, when associated Type of Claim value is in [‘4’, ‘D’] 10. Value must be populated when the associated Type of Claim (CIP.002.100) is in [‘5’, ‘E’]11. Value must not be greater than Total Allowed Amount (CIP.002.113) |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals "2", value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must be populated, when Type of Claim is in [1,A]8. Value must not be populated or equal to "0.00" when associated Claim Status is in [26,026,87,087,542,585,654]9. Value should not be populated, when associated Type of Claim value is in [4,D]10. Value must be populated when the associated Type of Claim (CIP.002.100) is in [5,E]11. Value must not be greater than Total Allowed Amount (CIP.002.113) |
| 09/12/2024 |
3.29.0 |
CIP.002.113 |
UPDATE |
Definition |
The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. On managed care encounters the Allowed Amount is determined by the managed care organization.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity allowed for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
The claim header level maximum amount determined by the payer as being "allowable" under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state"s MMIS. On managed care encounters the Allowed Amount is determined by the managed care organization.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity allowed for the service. Report a null value in this field if the provider is a sub-capitated network provider.
For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field.
|
| 09/12/2024 |
3.29.0 |
CIP.002.113 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. When populated and Payment Level Indicator = '2' then value must equal the sum of all claim line Allowed Amount values4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. When populated and Payment Level Indicator equals "2" then value must equal the sum of all claim line Allowed Amount values4. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.112 |
UPDATE |
Definition |
The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. Report a null value in this field if the provider is a sub-capitated network provider.
For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 09/12/2024 |
3.29.0 |
CIP.002.112 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must equal the sum of all Billed Amount instances for the associated claim4. Conditional5. When associated Type of Claim in [‘1’, ’3’, ’A’, ’C’], value must be populated6. (individual line item payments) when populated and Payment Level Indicator (CIP.002.132) equals = '2' value must be greater than or equal to the sum of all claim line Revenue Charges (CIP.003.251) |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Value must equal the sum of all Billed Amount instances for the associated claim4. Conditional5. When associated Type of Claim in [1,3,A,C] and Source Location does not equal "23", value must be populated6. (individual line item payments) when populated and Payment Level Indicator (CIP.002.132) equals "2" value must be greater than or equal to the sum of all claim line Revenue Charges (CIP.003.251) |
| 09/12/2024 |
3.29.0 |
CIP.002.104 |
UPDATE |
Definition |
The field denotes the claims payment system from which the claim was extracted.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = '22' to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis.For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = '23' to indicate that the sub-capitated network provider provided the service directly to the enrollee.For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = “23” to indicate that the sub-capitated network provider provided the service directly to the enrollee. |
The field denotes the claims payment system from which the claim was extracted.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = "22" to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis.
For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = "23" to indicate that the sub-capitated network provider provided the service directly to the enrollee.
For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = “23” to indicate that the sub-capitated network provider provided the service directly to the enrollee. |
| 09/12/2024 |
3.29.0 |
CIP.002.103 |
UPDATE |
Coding requirement |
1. Value must be in Claim Status Category List (VVL)2. (Denied Claim) if associated Claim Denied Indicator indicates the claim was denied, then value must be "F2"3. (Denied Claim) if associated Claim Status is in [ 542, 585, 654 ], then value must be "F2"4. Value must be 3 characters or less5. Mandatory |
1. Value must be in Claim Status Category List (VVL)2. (Denied Claim) if associated Claim Denied Indicator indicates the claim was denied, then value must be "F2"3. (Denied Claim) if associated Claim Status is in [542,585,654 ], then value must be "F2"4. Value must be 3 characters or less5. Mandatory |
| 09/12/2024 |
3.29.0 |
CIP.002.102 |
UPDATE |
Coding requirement |
1. Value must be in Claim Status List (VVL)2. Value must be 3 characters or less3. Conditional4. If value in [ 542, 585, 654 ], Claim Denied Indicator must be '0' and Claim Status Category must be 'F2' |
1. Value must be in Claim Status List (VVL)2. Value must be 3 characters or less3. Conditional4. If value in [542,585,654], Claim Denied Indicator must be "0" and Claim Status Category must be "F2" |
| 09/12/2024 |
3.29.0 |
CIP.002.101 |
UPDATE |
Coding requirement |
1. Value must be in Type of Bill List (VVL)2. Value must be 4 characters3. First character must be a '0'4. Mandatory |
1. Value must be in Type of Bill List (VVL)2. Value must be 4 characters3. First character must be a "0"4. Mandatory |
| 09/12/2024 |
3.29.0 |
CIP.002.100 |
UPDATE |
Definition |
A code to indicate what type of payment is covered in this claim.For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record. |
A code to indicate what type of payment is covered in this claim. For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = "3" for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record. |
| 09/12/2024 |
3.29.0 |
CIP.002.100 |
UPDATE |
Coding requirement |
1. Value must be in Type of Claim List (VVL)2. Value must be 1 character3. Mandatory4. When value equals 'Z', claim denied indicator must equal '0' |
1. Value must be in Type of Claim List (VVL)2. Value must be 1 character3. Mandatory4. When value equals "Z", claim denied indicator must equal "0" |
| 09/12/2024 |
3.29.0 |
CIP.002.096 |
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. Value must be less than or equal to associated Adjudication Date value.4. Value must be greater than or equal to associated Admission Date value.5. Value must be greater than or equal to associated eligible Date of Birth value.6. Value must be less than or equal to associated eligible Date of Death value.7. Conditional8. If associated Adjustment Indicator (CIP.002.026) does not equal "1" (Non-denied claims) and Patient Status (CIP.002.199) is not equal to "30" value must be populated.9. When populated, Discharge Hour (CIP.002.097) must be populated |
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. Value must be less than or equal to associated Adjudication Date value4. Value must be greater than or equal to associated Admission Date value5. Value must be greater than or equal to associated eligible Date of Birth value6. Value must be less than or equal to associated eligible Date of Death value7. Conditional8. If associated Adjustment Indicator (CIP.002.026) does not equal "1" (Non-denied claims) and Patient Status (CIP.002.199) is not equal to "30" value must be populated9. When populated, Discharge Hour (CIP.002.097) must be populated |
| 09/12/2024 |
3.29.0 |
CIP.002.094 |
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. Value must be less than or equal to associated Discharge Date value in the claim header.4. Value must be greater than or equal to associated eligible Date of Birth value.5. Value must be less than or equal to associated eligible Date of Death value.6. Mandatory7. Value must be between Enrollment Effective Date (ELG.021.253) and Enrollment End Date (ELG.021.254)8. (capitated payment) when associated Type of Claim (CIP.002.100) is not '2','B' or 'V' and Type of Service (CIP.002.257) is not '119, '120', '121', 122' value must be before Adjudication Date (CIP.003.286) |
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. Value must be less than or equal to associated Discharge Date value in the claim header.4. Value must be greater than or equal to associated eligible Date of Birth value5. Value must be less than or equal to associated eligible Date of Death value6. Mandatory7. Value must be between Enrollment Effective Date (ELG.021.253) and Enrollment End Date (ELG.021.254)8. (capitated payment) when associated Type of Claim (CIP.002.100) is not in [2,B,V] and Type of Service (CIP.002.257) is not in [119,120,121,122] value must be before Adjudication Date (CIP.003.286) |
| 09/12/2024 |
3.29.0 |
CIP.002.090 |
UPDATE |
Coding requirement |
1. When populated, there must be a corresponding Procedure Code Flag2. If associated Procedure Code Flag List (VVL) value indicates an ICD-9-CM encoding '02', then value must be a valid ICD-9-CM procedure code3. If associated Procedure Code Flag List (VVL) value indicates an ICD-10-CM encoding '07', then value must be a valid ICD-10-CM procedure code4. 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 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 ICD-9-CM encoding "02", then value must be a valid ICD-9-CM procedure code3. If associated Procedure Code Flag List (VVL) value indicates an ICD-10-CM encoding "07", then value must be a valid ICD-10-CM procedure code4. 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 code5. Value must be 8 characters or less6. Value must be in Procedure Code List (VVL)7. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.086 |
UPDATE |
Coding requirement |
1. When populated, there must be a corresponding Procedure Code Flag2. If associated Procedure Code Flag List (VVL) value indicates an ICD-9-CM encoding '02', then value must be a valid ICD-9-CM procedure code3. If associated Procedure Code Flag List (VVL) value indicates an ICD-10-CM encoding '07', then value must be a valid ICD-10-CM procedure code4. 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 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 ICD-9-CM encoding "02", then value must be a valid ICD-9-CM procedure code3. If associated Procedure Code Flag List (VVL) value indicates an ICD-10-CM encoding "07", then value must be a valid ICD-10-CM procedure code4. 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 code5. Value must be 8 characters or less6. Value must be in Procedure Code List (VVL)7. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.082 |
UPDATE |
Coding requirement |
1. When populated, there must be a corresponding Procedure Code Flag2. If associated Procedure Code Flag List (VVL) value indicates an ICD-9-CM encoding '02', then value must be a valid ICD-9-CM procedure code3. If associated Procedure Code Flag List (VVL) value indicates an ICD-10-CM encoding '07', then value must be a valid ICD-10-CM procedure code4. 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 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 ICD-9-CM encoding "02", then value must be a valid ICD-9-CM procedure code3. If associated Procedure Code Flag List (VVL) value indicates an ICD-10-CM encoding "07", then value must be a valid ICD-10-CM procedure code4. 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 code5. Value must be 8 characters or less6. Value must be in Procedure Code List (VVL)7. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.078 |
UPDATE |
Coding requirement |
1. When populated, there must be a corresponding Procedure Code Flag2. If associated Procedure Code Flag List (VVL) value indicates an ICD-9-CM encoding '02', then value must be a valid ICD-9-CM procedure code3. If associated Procedure Code Flag List (VVL) value indicates an ICD-10-CM encoding '07', then value must be a valid ICD-10-CM procedure code4. 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 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 ICD-9-CM encoding "02", then value must be a valid ICD-9-CM procedure code3. If associated Procedure Code Flag List (VVL) value indicates an ICD-10-CM encoding "07", then value must be a valid ICD-10-CM procedure code4. 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 code5. Value must be 8 characters or less6. Value must be in Procedure Code List (VVL)7. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.074 |
UPDATE |
Coding requirement |
1. When populated, there must be a corresponding Procedure Code Flag2. If associated Procedure Code Flag List (VVL) value indicates an ICD-9-CM encoding '02', then value must be a valid ICD-9-CM procedure code3. If associated Procedure Code Flag List (VVL) value indicates an ICD-10-CM encoding '07', then value must be a valid ICD-10-CM procedure code4. 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 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 ICD-9-CM encoding "02", then value must be a valid ICD-9-CM procedure code3. If associated Procedure Code Flag List (VVL) value indicates an ICD-10-CM encoding "07", then value must be a valid ICD-10-CM procedure code4. 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 code5. Value must be 8 characters or less6. Value must be in Procedure Code List (VVL)7. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.072 |
UPDATE |
Coding requirement |
1. When populated, there must be a corresponding Procedure Code2. Value must be in Procedure Code Flag List (VVL)3. Value must be 2 characters4. Conditional5. If Procedure Code 1 (CIP.002.070) is populated, Procedure Code Flag 1 (CIP.002.072) must be '02' (ICD-9 CM) or '07' (ICD-10 - CM PCS). |
1. When populated, there must be a corresponding Procedure Code2. Value must be in Procedure Code Flag List (VVL)3. Value must be 2 characters4. Conditional5. If Procedure Code 1 (CIP.002.070) is populated, Procedure Code Flag 1 (CIP.002.072) must be "02" (ICD-9 CM) or "07" (ICD-10-CM PCS). |
| 09/12/2024 |
3.29.0 |
CIP.002.070 |
UPDATE |
Coding requirement |
1. When populated, there must be a corresponding Procedure Code Flag2. If associated Procedure Code Flag List (VVL) value indicates an ICD-9-CM encoding '02', then value must be a valid ICD-9-CM procedure code3. If associated Procedure Code Flag List (VVL) value indicates an ICD-10-CM encoding '07', then value must be a valid ICD-10-CM procedure code4. 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 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 ICD-9-CM encoding "02", then value must be a valid ICD-9-CM procedure code3. If associated Procedure Code Flag List (VVL) value indicates an ICD-10-CM encoding "07", then value must be a valid ICD-10-CM procedure code4. 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 code5. Value must be 8 characters or less6. Value must be in Procedure Code List (VVL)7. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.069 |
UPDATE |
Coding requirement |
1. Value must be 4 characters or less2. The right-most 2 positions must be found in 01-993. Conditional4. Value must be populated, when associated Diagnosis Related Group (CIP.002.068) is populated |
1. Value must be 4 characters or less2. The right-most 2 positions must be in [01-99]3. Conditional4. Value must be populated, when associated Diagnosis Related Group (CIP.002.068) is populated |
| 09/12/2024 |
3.29.0 |
CIP.002.025 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Conditional5. When value equals '0', is invalid or not populated, then the associated 1115A Demonstration Indicator (ELG.018.233) must equal '0', is invalid or not populated |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Conditional5. When value equals "0", is invalid or not populated, then the associated 1115A Demonstration Indicator (ELG.018.233) must equal "0", is invalid or not populated |
| 09/12/2024 |
3.29.0 |
CIP.002.023 |
UPDATE |
Coding requirement |
1. Value must be in Crossover Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service)5. If the Type of Claim value is in ["1", "3", "A", "C"], then value is mandatory and must be reported6. Conditional |
1. Value must be in Crossover Indicator List (VVL)2. Value must be 1 character3. Value must be in [0,1] or not populated4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in [01,02,04,08,09,10] for the same time period (by date of service)5. If the Type of Claim value is in [1,3,A,C], then value is mandatory and must be reported6. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.022 |
UPDATE |
Coding requirement |
1. Mandatory2. Value must be 20 characters or less3. When Type of Claim not in (4, D, X, Z, U, V, Y, W), value must match MSIS Identification Number (ELG.021.251) and the Admission Date (CIP.002.094) must be between Enrollment Effective Date (ELG.021.253) and Enrollment End Date (ELG.021.254)4. When Type of Claim (CIP.002.100) equals 4, D or X (lump sum payment) value must begin with an '&' |
1. Mandatory2. Value must be 20 characters or less3. When Type of Claim not in [4,D,X,Z,U,V,Y,W], value must match MSIS Identification Number (ELG.021.251) and the Admission Date (CIP.002.094) must be between Enrollment Effective Date (ELG.021.253) and Enrollment End Date (ELG.021.254)4. When Type of Claim (CIP.002.100) equals 4, D or X (lump sum payment) value must begin with an "&" |
| 09/12/2024 |
3.29.0 |
CIP.002.020 |
UPDATE |
Coding requirement |
Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [‘4’, ‘1’] then value must be populated |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is "0", then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [4,1] then value must be populated |
| 09/12/2024 |
3.29.0 |
CIP.001.011 |
UPDATE |
Coding requirement |
1. For production files, value must be equal to 'P'2. Value must be in File Status Indicator List (VVL)3. Value must be 1 character4. Mandatory |
1. For production files, value must be equal to "P"2. Value must be in File Status Indicator List (VVL)3. Value must be 1 character4. Mandatory |
| 09/12/2024 |
3.29.0 |
CIP.001.006 |
UPDATE |
Coding requirement |
1. Value must equal 'CLAIM-IP'2. Mandatory |
1. Value must equal "CLAIM-IP"2. Mandatory |
| 09/07/2023 |
3.12.0 |
COT.003.184 |
UPDATE |
Definition |
The maximum allowable quantity of a service that may be rendered per date of service or per month. For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMOT claims/encounter records, use the Revenue center -quantity Allowed field. NOTE: One prescription for 100 250 milligram tablets results in Prescription Quantity allowed=100.This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled. For prescriptions/refills, use the Medicaid Drug Rebate definition of a unit, which is the smallest unit by which the drug is normally measured; e.g. tablet, capsule, milliliter, etc. For drugs not identifiable or dispensed by a normal unit, e.g. powder filled vials, use 1 as the number of units. The value in Prescription Quantity allowed must correspond with the value in Unit of measure. |
The maximum allowable quantity of a service that may be rendered per date of service or per month. For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMOT claims/encounter records, use the Revenue center -quantity Allowed field. NOTE: One prescription for 100 250 milligram tablets results in Prescription Quantity allowed=100. This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled. For prescriptions/refills, use the Medicaid Drug Rebate definition of a unit, which is the smallest unit by which the drug is normally measured; e.g. tablet, capsule, milliliter, etc. For drugs not identifiable or dispensed by a normal unit, e.g. powder filled vials, use 1 as the number of units. The value in Prescription Quantity allowed must correspond with the value in Unit of measure. |
| 11/15/2023 |
3.16.0 |
Data Quality Measures |
UPDATE |
Version text |
3.9.0 |
3.10.0 |
| 09/06/2023 |
3.12.0 |
RULE-7411 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
RULE-7408 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
RULE-7407 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
RULE-7371 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
RULE-7370 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
RULE-7369 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
RULE-7368 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
RULE-7367 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
RULE-7366 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
RULE-7423 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
ALL-40-001-1 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
ALL-39-001-1 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
ALL-38-001-1 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
ALL-37-001-1 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
MCR-12-163-163 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
MCR-12-162-162 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
MCR-12-161-161 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
MCR-12-160-160 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
MCR-12-159-159 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
MCR-12-158-158 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
MCR-12-157-157 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
MCR-12-156-156 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
MIS-11-010_10-58 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
MCR-59R-004-16 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
MCR-59R-003-15 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
MCR-59R-002-14 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
MCR-59R-001-13 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
MCR-56R-001-1 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
EXP-41R-001-1 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
EXP-22R-009-9 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
EXP-37R-001-1-2 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
EXP-33R-001-1 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
EXP-29R-001-1 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
MCR-59P-004-16 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
MCR-59P-003-15 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
MCR-59P-002-14 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
MCR-59P-001-13 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
MCR-56P-001-1 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
EXP-41P-001-1 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
EXP-22P-009-9 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
EXP-37P-001-1-2 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
EXP-33P-001-1 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
EXP-29P-001-1 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
RULE-7641 |
ADD |
N/A |
|
Created |
| 09/07/2023 |
3.12.0 |
Data Quality Measures |
UPDATE |
Version text |
3.8.0 |
3.9.0 |
| 09/06/2023 |
3.12.0 |
Data Quality Measures |
UPDATE |
Thresholds document |
250 |
253 |
| 09/21/2023 |
3.13.0 |
CRX.002.101 |
UPDATE |
Coding requirement |
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 |
| 09/21/2023 |
3.13.0 |
COT.002.143 |
UPDATE |
Coding requirement |
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 Amount 4. 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 |
| 09/21/2023 |
3.13.0 |
CLT.002.166 |
UPDATE |
Coding requirement |
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 Amount 4. 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 |
| 09/21/2023 |
3.13.0 |
CIP.002.219 |
UPDATE |
Coding requirement |
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 Amount 4. 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 |
| 08/28/2023 |
3.12.0 |
CLT.002.065 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must not be greater than Total Allowed Amount8. Value must be populated, when Type of Claim is in [‘1’, ‘A’]9. Value must not be populated or equal to ‘0.00’ when associated Claim Status is in ['26', '026', '87', '087', '542', '585', '654']10. Value should not be populated, when associated Type of Claim value is in [‘4’, ‘D’] 11. Value must be less than Total Allowed Amount12. Value must be populated when the associated Type of Claim (CLT.002.052) is in [‘5’, ‘E’] |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must not be greater than Total Allowed Amount8. Value must be populated, when Type of Claim is in [‘1’, ‘A’]9. Value must not be populated or equal to ‘0.00’ when associated Claim Status is in ['26', '026', '87', '087', '542', '585', '654']10. Value should not be populated, when associated Type of Claim value is in [‘4’, ‘D’] 11. Value must be less than Total Allowed Amount11. Value must be populated when the associated Type of Claim (CLT.002.052) is in [‘5’, ‘E’] |
| 08/28/2023 |
3.12.0 |
COT.002.050 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must not be greater than Total Allowed Amount (COT.002.049)8. Value must not be populated or equal to ‘0.00’ when associated Claim Status is in ['26', '026', '87', '087', '542', '585', '654']9. Value should not be populated, when associated Type of Claim value is in [‘4’, ‘D’] 10. Value must not be greater than Total Allowed Amount (COT.002.049) 11. Value must be populated, when Type of Claim (COT.002.037) is in [‘2’, '5', ‘B’, 'E'] |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must be populated, when Type of Claim is in [‘1’, ‘A’]8. Value must not be populated or equal to ‘0.00’ when associated Claim Status is in ['26', '026', '87', '087', '542', '585', '654']9. Value should not be populated, when associated Type of Claim value is in [‘4’, ‘D’] 10. Value must not be greater than Total Allowed Amount (COT.002.049) 11. Value must be populated, when Type of Claim (COT.002.037) is in [‘2’, '5', ‘B’, 'E'] |
| 09/21/2023 |
3.13.0 |
ELG.012.172 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/28/2023 |
3.12.0 |
ELG.012.172 |
UPDATE |
Coding requirement |
1. Value must have a corresponding value in Waiver Type (ELG.012.173)2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by a version number [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Value must have a corresponding value in Waiver Type (ELG.012.173)7. Mandatory |
1. Value must have a corresponding value in Waiver Type (ELG.012.173)2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by a version number [0-9] in the 12th position5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Mandatory |
| 08/28/2023 |
3.12.0 |
ELG.012.172 |
UPDATE |
Coding requirement |
Value must have a corresponding value in Waiver Type (ELG.012.173)2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by a version number [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Value must have a corresponding value in Waiver Type (ELG.012.173)7. Mandatory |
1. Value must have a corresponding value in Waiver Type (ELG.012.173)2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by a version number [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Value must have a corresponding value in Waiver Type (ELG.012.173)7. Mandatory |
| 08/28/2023 |
3.12.0 |
ELG.012.172 |
UPDATE |
Coding requirement |
1. Value must have a corresponding value in Waiver Type (ELG.012.173)2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Value must have a corresponding value in Waiver Type (ELG.012.173)6. Mandatory |
Value must have a corresponding value in Waiver Type (ELG.012.173)2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by a version number [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Value must have a corresponding value in Waiver Type (ELG.012.173)7. Mandatory |
| 08/28/2023 |
3.12.0 |
MCR.003.050 |
UPDATE |
Coding requirement |
Must contain the '@' symbol2. May contain uppercase and lowercase Latin letters A to Z and a to z3. May contain digits 0-94. Must contain a dot '.' that is not the first or last character and provided that it does not appear consecutively5. Value must be 60 characters or less6. Situational |
1. Must contain the '@' symbol2. May contain uppercase and lowercase Latin letters A to Z and a to z3. May contain digits 0-94. Must contain a dot '.' that is not the first or last character and provided that it does not appear consecutively5. Value must be 60 characters or less6. Situational |
| 09/21/2023 |
3.13.0 |
ELG.009.140 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 09/21/2023 |
3.13.0 |
ELG.013.183 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/21/2023 |
3.13.0 |
TPL.006.082 |
UPDATE |
Medicaid valid value info |
|
Zip Code List |
| 09/21/2023 |
3.13.0 |
CRX.003.113 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 09/21/2023 |
3.13.0 |
CRX.002.020 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 09/21/2023 |
3.13.0 |
COT.003.159 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 09/21/2023 |
3.13.0 |
COT.002.020 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 09/21/2023 |
3.13.0 |
CLT.003.189 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 09/21/2023 |
3.13.0 |
CLT.002.020 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 09/21/2023 |
3.13.0 |
CIP.003.236 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 09/21/2023 |
3.13.0 |
CIP.002.020 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/28/2023 |
3.12.0 |
COT.002.146 |
UPDATE |
Coding requirement |
Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. When Type of Service (COT.003.186) equals '121', value must not be populated5. 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. Conditional4. When Type of Service (COT.003.186) equals '121', value must not be populated5. Value must exist in the NPPES NPI data file |
| 09/21/2023 |
3.13.0 |
ELG.022.265 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/06/2023 |
3.12.0 |
TPL.001.002 |
UPDATE |
Definition |
A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary". |
A data element to capture the version of the T-MSIS data dictionary that was used to build the file. |
| 09/06/2023 |
3.12.0 |
PRV.001.002 |
UPDATE |
Definition |
A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary". |
A data element to capture the version of the T-MSIS data dictionary that was used to build the file. |
| 09/06/2023 |
3.12.0 |
MCR.001.002 |
UPDATE |
Definition |
A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary". |
A data element to capture the version of the T-MSIS data dictionary that was used to build the file. |
| 09/06/2023 |
3.12.0 |
ELG.001.002 |
UPDATE |
Definition |
A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary". |
A data element to capture the version of the T-MSIS data dictionary that was used to build the file. |
| 09/06/2023 |
3.12.0 |
CRX.001.002 |
UPDATE |
Definition |
A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary". |
A data element to capture the version of the T-MSIS data dictionary that was used to build the file. |
| 09/06/2023 |
3.12.0 |
COT.001.002 |
UPDATE |
Definition |
A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary". |
A data element to capture the version of the T-MSIS data dictionary that was used to build the file. |
| 09/06/2023 |
3.12.0 |
CLT.001.002 |
UPDATE |
Definition |
A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary". |
A data element to capture the version of the T-MSIS data dictionary that was used to build the file. |
| 08/28/2023 |
3.12.0 |
CLT.001.002 |
UPDATE |
Coding requirement |
Value must be 10 characters or less2. Value must be in the Data Dictionary Version List (VVL)3. Mandatory |
1. Value must be 10 characters or less2. Value must be in the Data Dictionary Version List (VVL)3. Mandatory |
| 09/21/2023 |
3.13.0 |
CIP.001.002 |
UPDATE |
Definition |
A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary". |
A data element to capture the version of the T-MSIS data dictionary that was used to build the file. |
| 08/28/2023 |
3.12.0 |
COT.002.137 |
UPDATE |
Definition |
Not Applicable |
An indicator signifying that the copay was discounted or waived by the provider (e.g., physician or hospital). Do not use to indicate administrative-level, Medicaid State Agency or Medicaid MCO copayment waived decisions. |
| 08/29/2023 |
3.12.0 |
CRX.002.101 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
CRX.002.101 |
UPDATE |
Coding requirement |
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 Amount 4. Situational |
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 |
| 08/29/2023 |
3.12.0 |
COT.002.143 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
CLT.002.166 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
CIP.002.219 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/23/2023 |
3.12.0 |
CLT.002.166 |
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. Must have an associated Third Party Copayment Amount4. Situational |
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 Amount 4. Situational |
| 08/23/2023 |
3.12.0 |
CIP.002.219 |
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. Must have an associated Third Party Copayment Amount4. Situational |
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 Amount 4. Situational |
| 08/29/2023 |
3.12.0 |
CRX.002.100 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
COT.002.142 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
CLT.002.165 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
CIP.002.218 |
UPDATE |
Necessity |
Optional |
Situational |
| 09/21/2023 |
3.13.0 |
CRX.002.099 |
UPDATE |
Coding requirement |
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 Amount 4. 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 |
| 09/21/2023 |
3.13.0 |
COT.002.141 |
UPDATE |
Coding requirement |
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 Amount 4. 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 |
| 09/21/2023 |
3.13.0 |
CLT.002.164 |
UPDATE |
Coding requirement |
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 Amount 4. 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 |
| 09/21/2023 |
3.13.0 |
CIP.002.217 |
UPDATE |
Coding requirement |
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 Amount 4. 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 |
| 08/29/2023 |
3.12.0 |
CRX.002.098 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
COT.002.140 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
CLT.002.163 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
CIP.002.216 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
TPL.006.086 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/21/2023 |
3.12.0 |
TPL.006.086 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 08/29/2023 |
3.12.0 |
TPL.005.070 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
TPL.004.061 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
TPL.003.050 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
TPL.002.027 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
TPL.001.014 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
PRV.010.136 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
PRV.009.123 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
PRV.008.113 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
PRV.007.104 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
PRV.006.092 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
PRV.005.082 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
PRV.004.070 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
PRV.003.058 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
PRV.002.037 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
PRV.001.014 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
MCR.007.089 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
MCR.006.080 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
MCR.005.071 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
MCR.004.061 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
MCR.003.052 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
MCR.002.032 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
MCR.001.014 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.022.267 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.021.255 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.020.245 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.018.236 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.017.227 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.016.218 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.015.207 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.014.198 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.013.186 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.012.176 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.011.166 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.010.157 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.009.144 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.008.134 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.007.124 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.006.112 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.005.101 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.004.077 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.003.059 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.002.028 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.001.014 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
CRX.003.153 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
CRX.002.106 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
CRX.001.014 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
COT.003.214 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
COT.002.152 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
COT.001.014 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
CLT.003.226 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
CLT.002.173 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
CLT.001.014 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
CIP.003.273 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
CIP.002.229 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
CIP.001.014 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/16/2023 |
3.12.0 |
CIP.003.269 |
UPDATE |
Coding requirement |
1. Value must be in CMS 64 Category for Federal Reimbursement List (VVL)2. Value must be 2 characters3. (Federal Funding under Title XXI) if value equals '02', then the eligible's CHIP Code (ELG.003.054) must be in ['2', '3']4. (Federal Funding under Title XIX) if value equals '01' then the eligible's CHIP Code (ELG.003.054) must be '1'5. Conditional6. If Type of Claim is in ['1','2','5','A','B','E','U','V','Y'] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported7. If Type of Claim is in ['4','D'] and the Service Tracking Payment Amount on the relevant record is populated, then value must be reported8. When Type of Claim is in [‘1’, ‘A’], value must be populated |
1. Value must be in CMS 64 Category for Federal Reimbursement List (VVL)2. Value must be 2 characters3. (Federal Funding under Title XXI) if value equals '02', then the eligible's CHIP Code (ELG.003.054) must be in ['2', '3']4. (Federal Funding under Title XIX) if value equals '01' then the eligible's CHIP Code (ELG.003.054) must be '1'5. Conditional6. If Type of Claim is in ['1','2','5','A','B','E','U','V','Y'] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported7. If Type of Claim is in ['4','D'] and the Service Tracking Payment Amount on the relevant record is populated, then value must be reported8. When Type of Claim is in [‘1’,‘A’], value must be populated |
| 08/16/2023 |
3.12.0 |
CIP.003.269 |
UPDATE |
Coding requirement |
Value must be in CMS 64 Category for Federal Reimbursement List (VVL)2. Value must be 2 characters3. (Federal Funding under Title XXI) if value equals '02', then the eligible's CHIP Code (ELG.003.054) must be in ['2', '3']4. (Federal Funding under Title XIX) if value equals '01' then the eligible's CHIP Code (ELG.003.054) must be '1'5. Conditional6. If Type of Claim is in ['1','2','5','A','B','E','U','V','Y'] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported.7. If Type of Claim is in ['4','D'] and the Service Tracking Payment Amount on the relevant record is populated, then value must be reported.8. When Type of Claim is in [‘1’, ‘A’], value must be populated |
1. Value must be in CMS 64 Category for Federal Reimbursement List (VVL)2. Value must be 2 characters3. (Federal Funding under Title XXI) if value equals '02', then the eligible's CHIP Code (ELG.003.054) must be in ['2', '3']4. (Federal Funding under Title XIX) if value equals '01' then the eligible's CHIP Code (ELG.003.054) must be '1'5. Conditional6. If Type of Claim is in ['1','2','5','A','B','E','U','V','Y'] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported7. If Type of Claim is in ['4','D'] and the Service Tracking Payment Amount on the relevant record is populated, then value must be reported8. When Type of Claim is in [‘1’, ‘A’], value must be populated |
| 08/16/2023 |
3.12.0 |
COT.002.112 |
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.002.019) Submitting State Provider ID or4. 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 where the Provider Identifier Type (PRV.005.081) equal to '1' 5. When Type of Claim is in ['1','3','A','C'], then value must be populated 6. 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)7. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or8. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) 9. When Type of Service (COT.003.186) is not in ['119', ‘120’, ‘122’], value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1' |
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.002.019) Submitting State Provider ID or4. 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 where the Provider Identifier Type (PRV.005.081) equal to '1' 5. When Type of Claim is in ['1','3','A','C'], then value must be populated6. 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)7. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or8. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080)9. When Type of Service (COT.003.186) is not in ['119', ‘120’, ‘122’], value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1' |
| 08/16/2023 |
3.12.0 |
CRX.002.071 |
UPDATE |
Coding requirement |
1. Value must be 10 digits 2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to '2' 3. Value must exist in the NPPES NPI data file 4. Conditional 5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal '01' 6. When Type of Claim is in ['1','3','A','C'], then value must be populated 7. When Type of Claim not in ('3','C','W') then value must match Provider Identifier (PRV.002.081) 8. NPPES Entity Type Code associated with this NPI must equal ‘2’ (Organization) |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to '2'3. Value must exist in the NPPES NPI data file4. Conditional5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal '01'6. When Type of Claim is in ['1','3','A','C'], then value must be populated7. When Type of Claim not in ('3','C','W') then value must match Provider Identifier (PRV.002.081) 8. NPPES Entity Type Code associated with this NPI must equal ‘2’ (Organization) |
| 08/16/2023 |
3.12.0 |
CIP.002.180 |
UPDATE |
Coding requirement |
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 file 4. Conditional5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal '01'6. When Type of Claim is in ['1','3','A','C'], then value must be populated 7. NPPES Entity Type Code associated with this NPI must equal ‘2’ (Organization) |
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 populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal '01'6. When Type of Claim is in ['1','3','A','C'], then value must be populated7. NPPES Entity Type Code associated with this NPI must equal ‘2’ (Organization) |
| 08/16/2023 |
3.12.0 |
COT.003.176 |
UPDATE |
Coding requirement |
1. Situational2. Value must be between -99999999999.99 and 99999999999.993. Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) |
1. Situational2. Value must be between -99999999999.99 and 99999999999.993. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )4. Value must be 11 digits or less left of the decimal i.e. 9999999999 99 |
| 09/21/2023 |
3.13.0 |
CRX.002.025 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/21/2023 |
3.13.0 |
CRX.002.025 |
UPDATE |
Coding requirement |
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 '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’ |
| 09/21/2023 |
3.13.0 |
COT.002.025 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/21/2023 |
3.13.0 |
COT.002.025 |
UPDATE |
Coding requirement |
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 '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’ |
| 09/21/2023 |
3.13.0 |
CLT.002.025 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/21/2023 |
3.13.0 |
CLT.002.025 |
UPDATE |
Coding requirement |
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 '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’ |
| 09/21/2023 |
3.13.0 |
CIP.002.026 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/21/2023 |
3.13.0 |
CIP.002.026 |
UPDATE |
Coding requirement |
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 '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’ |
| 08/28/2023 |
3.12.0 |
ELG.012.172 |
UPDATE |
Coding requirement |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Value must have a corresponding value in Waiver Type (ELG.012.173)6. Mandatory |
1. Value must have a corresponding value in Waiver Type (ELG.012.173)2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Value must have a corresponding value in Waiver Type (ELG.012.173)6. Mandatory |
| 08/28/2023 |
3.12.0 |
CRX.002.069 |
UPDATE |
Coding requirement |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Conditional |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by a version number [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Conditional |
| 08/28/2023 |
3.12.0 |
COT.002.111 |
UPDATE |
Coding requirement |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Conditional |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by a version number [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Conditional |
| 08/28/2023 |
3.12.0 |
CLT.002.129 |
UPDATE |
Coding requirement |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Conditional |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by a version number [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Conditional |
| 08/28/2023 |
3.12.0 |
CIP.002.178 |
UPDATE |
Coding requirement |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Conditional |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by a version number [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Conditional |
| 09/06/2023 |
3.12.0 |
COT.003.205 |
UPDATE |
Definition |
The street address of the destination point to which a patient is transported either from home or Long term care facility to a health care provider for healthcare services or vice versa. For transportation claims only. Required if state has captured this information, otherwise it is conditional. |
The second line of the street address of the destination point to which a patient is transported either from home or Long term care facility to a health care provider for healthcare services or vice versa. For transportation claims only. Required if state has captured this information, otherwise it is conditional. |
| 08/14/2023 |
3.12.0 |
CIP.002.094 |
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. Value must be less than or equal to associated Discharge Date (CE) value in the claim header.4. Value must be greater than or equal to associated eligible Date of Birth (CE) value.5. Value must be less than or equal to associated eligible Date of Death (CE) value.6. Mandatory7. Value must be between Enrollment Effective Date (ELG.021.253) and Enrollment End Date (ELG.021.254)8. (capitated payment) when associated Type of Claim (CIP.002.100) is not '2','B' or 'V' and Type of Service (CIP.002.257) is not '119, '120', '121', 122' value must be before Adjudication Date (CIP.003.286) |
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. Value must be less than or equal to associated Discharge Date value in the claim header.4. Value must be greater than or equal to associated eligible Date of Birth value.5. Value must be less than or equal to associated eligible Date of Death value.6. Mandatory7. Value must be between Enrollment Effective Date (ELG.021.253) and Enrollment End Date (ELG.021.254)8. (capitated payment) when associated Type of Claim (CIP.002.100) is not '2','B' or 'V' and Type of Service (CIP.002.257) is not '119, '120', '121', 122' value must be before Adjudication Date (CIP.003.286) |
| 08/15/2023 |
3.12.0 |
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. Mandatory |
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’ |
| 08/28/2023 |
3.12.0 |
CRX.002.023 |
UPDATE |
Coding requirement |
1. Value must be in Crossover Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service)5. Value must be 1 character6. If the Type of Claim value is in ["1", "3", "A", "C"], then value is mandatory and must be reported.7. Conditional |
1. Value must be in Crossover Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service)5. If the Type of Claim value is in ["1", "3", "A", "C"], then value is mandatory and must be reported.6. Conditional |
| 09/21/2023 |
3.13.0 |
CRX.002.017 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
ELG.005.099 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 08/15/2023 |
3.12.0 |
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. Mandatory |
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’ |
| 08/28/2023 |
3.12.0 |
CIP.002.023 |
UPDATE |
Coding requirement |
1. Value must be in Crossover Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service)5. Value must be 1 character6. If the Type of Claim value is in ["1", "3", "A", "C"], then value is mandatory and must be reported.7. Conditional |
1. Value must be in Crossover Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service)5. If the Type of Claim value is in ["1", "3", "A", "C"], then value is mandatory and must be reported6. Conditional |
| 08/15/2023 |
3.12.0 |
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. Mandatory |
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’ |
| 08/28/2023 |
3.12.0 |
CLT.002.023 |
UPDATE |
Coding requirement |
1. Value must be in Crossover Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service)5. Value must be 1 character6. If the Type of Claim value is in ["1", "3", "A", "C"], then value is mandatory and must be reported.7. Conditional |
1. Value must be in Crossover Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service)5. If the Type of Claim value is in ["1", "3", "A", "C"], then value is mandatory and must be reported.6. Conditional |
| 09/21/2023 |
3.13.0 |
ELG.005.086 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/21/2023 |
3.13.0 |
CLT.002.017 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
ELG.005.082 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
CIP.002.017 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
ELG.004.071 |
UPDATE |
Medicaid valid value info |
|
Zip Code List |
| 08/15/2023 |
3.12.0 |
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. Mandatory |
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’ |
| 08/28/2023 |
3.12.0 |
COT.002.023 |
UPDATE |
Coding requirement |
1. Value must be in Crossover Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service)5. Value must be 1 character6. If the Type of Claim value is in ["1", "3", "A", "C"], then value is mandatory and must be reported.7. Conditional |
1. Value must be in Crossover Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service)5. If the Type of Claim value is in ["1", "3", "A", "C"], then value is mandatory and must be reported.6. Conditional |
| 09/21/2023 |
3.13.0 |
COT.002.017 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 08/11/2023 |
3.11.0 |
CRX - CLAIM PHARMACY |
UPDATE |
File name |
CRX - CLAIM PRESCRIPTION |
CRX - CLAIM PHARMACY |
| 08/15/2023 |
3.12.0 |
COT.003.175 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional4. When Type of Claim is in ['1', 'A'}, Medicaid Paid Amount (COT.003.177) is less than or equal to the value submitted |
| 08/11/2023 |
3.11.0 |
COT.002.037 |
UPDATE |
Definition |
A code to indicate what type of payment is covered in this claim.For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record. |
A code to indicate what type of payment is covered in this claim.For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record.For sub-capitation payments, report TYPE-OF-CLAIM = '6' or “F”. |
| 08/28/2023 |
3.12.0 |
CRX.002.041 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must be populated, when Type of Claim is in [‘1’, ‘A’]8. Value must not be populated or equal to ‘0.00’ when associated Claim Status is in ['26', '026', '87', '087', '542', '585', '654']9. Value should not be populated, when associated Type of Claim value is in [‘4’, ‘D’] |
| 08/28/2023 |
3.12.0 |
COT.002.050 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must not be greater than Total Allowed Amount (COT.002.049) |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must not be greater than Total Allowed Amount (COT.002.049)8. Value must not be populated or equal to ‘0.00’ when associated Claim Status is in ['26', '026', '87', '087', '542', '585', '654']9. Value should not be populated, when associated Type of Claim value is in [‘4’, ‘D’] 10. Value must not be greater than Total Allowed Amount (COT.002.049) 11. Value must be populated, when Type of Claim (COT.002.037) is in [‘2’, '5', ‘B’, 'E'] |
| 08/28/2023 |
3.12.0 |
CLT.002.065 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must not be greater than Total Allowed Amount |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must not be greater than Total Allowed Amount8. Value must be populated, when Type of Claim is in [‘1’, ‘A’]9. Value must not be populated or equal to ‘0.00’ when associated Claim Status is in ['26', '026', '87', '087', '542', '585', '654']10. Value should not be populated, when associated Type of Claim value is in [‘4’, ‘D’] 11. Value must be less than Total Allowed Amount12. Value must be populated when the associated Type of Claim (CLT.002.052) is in [‘5’, ‘E’] |
| 08/28/2023 |
3.12.0 |
CIP.002.114 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must not be greater than Total Allowed Amount (CIP.002.113) |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must be populated, when Type of Claim is in [‘1’, ‘A’]8. Value must not be populated or equal to ‘0.00’ when associated Claim Status is in ['26', '026', '87', '087', '542', '585', '654']9. Value should not be populated, when associated Type of Claim value is in [‘4’, ‘D’] 10. Value must be populated when the associated Type of Claim (CIP.002.100) is in [‘5’, ‘E’]11. Value must not be greater than Total Allowed Amount (CIP.002.113) |
| 08/28/2023 |
3.12.0 |
CRX.002.039 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must equal the sum of all Billed Amount instances for the associated claim4. Conditional5. Value should not be populated when associated Type of Claim is in [2, 4, 5, B, D E or X] |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must equal the sum of all Billed Amount instances for the associated claim4. Conditional5. When associated Type of Claim in [‘1’, ’3’, ’A’, ’C’], value must be populated |
| 08/28/2023 |
3.12.0 |
COT.002.048 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must equal the sum of all Billed Amount instances for the associated claim4. Conditional5. Value should not be populated when associated Type of Claim is in [2, 4, 5, B, D E or X] |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must equal the sum of all Billed Amount instances for the associated claim4. Conditional5. When associated Type of Claim in [‘1’, ’3’, ’A’, ’C’], value must be populated |
| 08/28/2023 |
3.12.0 |
CLT.002.063 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must equal the sum of all Billed Amount instances for the associated claim4. Conditional5. Value should not be populated when associated Type of Claim is in [2, 4, 5, B, D E or X]6. Value should not be populated when associated Type of Claim (CIP.002.100) is equal to '4', 'D' or 'X'7. (individual line item payments) when populated and Payment Level Indicator (CLT.002.082) equals = '2' value must be greater than or equal to the sum of all claim line Revenue Charges (CLT.003.204) |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must equal the sum of all Billed Amount instances for the associated claim4. Conditional5. When associated Type of Claim in [‘1’, ’3’, ’A’, ’C’], value must be populated 6. Value should not be populated when associated Type of Claim (CLT.002.052) is equal to '4', 'D' or 'X'7. (individual line item payments) when populated and Payment Level Indicator (CLT.002.082) equals = '2' value must be greater than or equal to the sum of all claim line Revenue Charges (CLT.003.204) |
| 08/28/2023 |
3.12.0 |
CIP.002.112 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must equal the sum of all Billed Amount instances for the associated claim4. Conditional5. Value should not be populated when associated Type of Claim is in [2, 4, 5, B, D E or X]6. (individual line item payments) when populated and Payment Level Indicator (CIP.002.132) equals = '2' value must be greater than or equal to the sum of all claim line Revenue Charges (CIP.003.251) |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must equal the sum of all Billed Amount instances for the associated claim4. Conditional5. When associated Type of Claim in [‘1’, ’3’, ’A’, ’C’], value must be populated6. (individual line item payments) when populated and Payment Level Indicator (CIP.002.132) equals = '2' value must be greater than or equal to the sum of all claim line Revenue Charges (CIP.003.251) |
| 08/09/2023 |
3.11.0 |
CIP.002.112 |
UPDATE |
Definition |
The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. Report a null value in this field if the provider is a sub-capitated network provider. |
The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 08/15/2023 |
3.12.0 |
CLT.003.204 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than or equal to associated Total Billed Amount (CE) value.4. When populated, associated claim line Revenue Charge must be populated5. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than or equal to associated Total Billed Amount value.4. When populated, associated claim line Revenue Charge must be populated5. Conditional |
| 08/15/2023 |
3.12.0 |
CIP.003.251 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than or equal to associated Total Billed Amount (CE) value.4. When populated, associated claim line Revenue Charge must be populated5. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than or equal to associated Total Billed Amount value4. When populated, associated claim line Revenue Charge must be populated5. Conditional |
| 09/01/2023 |
3.12.0 |
COT.003.178 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional4. Value should not be populated or equal to zero, when associated Claim Line Status is in ['26', '026', '87', '087', '542', '585', '654'] |
| 09/01/2023 |
3.12.0 |
CLT.003.208 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional4. Value should not be populated or equal to zero, when associated Claim Line Status is in ['26', '026', '87', '087', '542', '585', '654'] |
| 09/01/2023 |
3.12.0 |
CIP.003.254 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional4. Value should not be populated or equal to zero, when associated Claim Line Status is in ['26', '026', '87', '087', '542', '585', '654'] |
| 08/16/2023 |
3.12.0 |
COT.002.112 |
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.002.019) Submitting State Provider ID or4. 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 where the Provider Identifier5. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or6. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080)7. When Type of Service (COT.003.186) is not in ['119', '120', '122'], value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1' |
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.002.019) Submitting State Provider ID or4. 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 where the Provider Identifier Type (PRV.005.081) equal to '1' 5. When Type of Claim is in ['1','3','A','C'], then value must be populated 6. 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)7. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or8. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) 9. When Type of Service (COT.003.186) is not in ['119', ‘120’, ‘122’], value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1' |
| 08/09/2023 |
3.11.0 |
ELG.005.095 |
UPDATE |
Definition |
The reason for a complete loss/termination in an individual's eligibility for Medicaid and CHIP. The end date of the segment in which the value is reported must represent the date that the complete loss/termination of Medicaid and CHIP eligibility occurred. The reason for the termination represents the reason that the segment in which it was reported was closed. If for a single termination in eligibility for a single individual there are multiple distinct co-occurring values in the state's system explaining the reason for the termination, and if one of the multiple co-occurring values maps to T-MSIS ELIGIBILITY-CHANGE-REASON value '21' (Other) or '22' (Unknown), then the state should not report the co-occurring value '21' and/or '22' to T-MSIS. If there are multiple co-occurring distinct values between '01' and '19', then the state should choose whichever is first in the state's system. Of the values that could logically co-occur in the range of '01' through '19', CMS does not currently have a preference for any one value over another. Do not populate if at the time someone loses Medicaid eligibility they become eligible for and enrolled in CHIP. Also do not populate if at the time someone loses CHIP eligibility they become eligible for and enrolled in Medicaid.| |
The reason for a complete loss/termination in an individual's eligibility for Medicaid and CHIP. The end date of the segment in which the value is reported must represent the date that the complete loss/termination of Medicaid and CHIP eligibility occurred. The reason for the termination represents the reason that the segment in which it was reported was closed. If for a single termination in eligibility for a single individual there are multiple distinct co-occurring values in the state's system explaining the reason for the termination, and if one of the multiple co-occurring values maps to T-MSIS ELIGIBILITY-CHANGE-REASON value '21' (Other) or '22' (Unknown), then the state should not report the co-occurring value '21' and/or '22' to T-MSIS. If there are multiple co-occurring distinct values between '01' and '19', then the state should choose whichever is first in the state's system. Of the values that could logically co-occur in the range of '01' through '19', CMS does not currently have a preference for any one value over another. Do not populate if at the time someone loses Medicaid eligibility they become eligible for and enrolled in CHIP. Also do not populate if at the time someone loses CHIP eligibility they become eligible for and enrolled in Medicaid. |
| 09/21/2023 |
3.13.0 |
CRX.003.116 |
UPDATE |
Segment key field identifier |
Not Applicable |
6 |
| 09/21/2023 |
3.13.0 |
COT.003.162 |
UPDATE |
Segment key field identifier |
Not Applicable |
6 |
| 09/21/2023 |
3.13.0 |
CLT.003.192 |
UPDATE |
Segment key field identifier |
Not Applicable |
6 |
| 09/21/2023 |
3.13.0 |
CIP.003.239 |
UPDATE |
Segment key field identifier |
Not Applicable |
6 |
| 08/22/2023 |
3.12.0 |
ELG.016.215 |
UPDATE |
Definition |
"American Indian or Alaska Native" means any individual defined at 25 USC 1603(13), 1603(28), or 1679(a), or who has been determined eligible as an Indian, pursuant to 42 CFR 136.12. This means the individual: a. Is a member of a Federally-recognized Indian tribe; b. Resides in an urban center and meets one or more of the following four criteria: i. Is a member of a tribe, band, or other organized group of Indians, including those tribes, bands, or groups terminated since 1940 and those recognized now or in the future by the State in which they reside, or who is a descendant, in the first or second degree, of any such member; ii. Is an Eskimo or Aleut or other Alaska Native; iii. Is considered by the Secretary of the Interior to be an Indian for any purpose; or iv. Is determined to be an Indian under regulations promulgated by the `Secretary of Health and Human Services; c. Is considered by the Secretary of the Interior to be an Indian for any purpose; or d. Is considered by the Secretary of Health and Human Services to be an Indian for purposes of eligibility for Indian health care services, including as a California Indian, Eskimo, Aleut, or other Alaska Native. NOTE Applicants who complete Appendix B of the Marketplace/Medicaid application and respond affirmatively to the two questions shown below are considered to meet the definition of an American Indian/Alaskan Native. Are you a member of a federally recognized tribe? Has this person ever gotten a service from the Indian Health Service, a tribal health program, or urban Indian health program, or through a referral from one of these programs? |
"American Indian or Alaska Native" means any individual defined at 25 USC 1603(13), 1603(28), or 1679(a), or who has been determined eligible as an Indian, pursuant to 42 CFR 136.12. This means the individual: a. Is a member of a Federally-recognized Indian tribe; b. Resides in an urban center and meets one or more of the following four criteria: i. Is a member of a tribe, band, or other organized group of Indians, including those tribes, bands, or groups terminated since 1940 and those recognized now or in the future by the State in which they reside, or who is a descendant, in the first or second degree, of any such member; ii. Is an Eskimo or Aleut or other Alaska Native; iii. Is considered by the Secretary of the Interior to be an Indian for any purpose; or iv. Is determined to be an Indian under regulations promulgated by the Secretary of Health and Human Services; c. Is considered by the Secretary of the Interior to be an Indian for any purpose; or d. Is considered by the Secretary of Health and Human Services to be an Indian for purposes of eligibility for Indian health care services, including as a California Indian, Eskimo, Aleut, or other Alaska Native. NOTE Applicants who complete Appendix B of the Marketplace/Medicaid application and respond affirmatively to the two questions shown below are considered to meet the definition of an American Indian/Alaskan Native. Are you a member of a federally recognized tribe? Has this person ever gotten a service from the Indian Health Service, a tribal health program, or urban Indian health program, or through a referral from one of these programs? |
| 09/21/2023 |
3.13.0 |
ELG.018.233 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/07/2023 |
3.11.0 |
COT.002.136 |
UPDATE |
Coding requirement |
1. Value must be in Claim Denied Indicator List (VVL)2. If value is '0', then Claim Status Category (CE) must equal "F2"3. Value must be 1 character4. Mandatory |
1. Value must be in Claim Denied Indicator List (VVL)2. If value is '0', then Claim Status Category must equal "F2"3. Value must be 1 character4. Mandatory |
| 08/28/2023 |
3.12.0 |
CLT.003.225 |
UPDATE |
Coding requirement |
1. Value must be in XXI MBESCBES Category of Service List (VVL)2. Conditional3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is '2', then a valid value is mandatory and must be reported4. If XIX MBESCBES Category of Service is populated then value must not be populated5. Value must be 3 characters or less |
1. Value must be in XXI MBESCBES Category of Service List (VVL)2. Conditional3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is '02', then a valid value is mandatory and must be reported4. If XIX MBESCBES Category of Service is populated then value must not be populated5. Value must be 3 characters or less |
| 08/28/2023 |
3.12.0 |
CLT.003.224 |
UPDATE |
Coding requirement |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is '1', then a valid value is mandatory and must be reported5. If value is in ['14', '35', '42' or '44'], then Sex (ELG.002.023) must not equals 'M'6. If XXI MBESCBES Category of Service is populated then must not be populated |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is '01', then a valid value is mandatory and must be reported5. If value is in ['14', '35', '42' or '44'], then Sex (ELG.002.023) must not equals 'M'6. If XXI MBESCBES Category of Service is populated then must not be populated |
| 08/07/2023 |
3.11.0 |
CRX.002.025 |
UPDATE |
Coding requirement |
1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim (CE) 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 (CE) value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory |
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. Mandatory |
| 08/09/2023 |
3.11.0 |
COT.002.112 |
UPDATE |
Definition |
A unique identification number assigned by the state to a provider or capitation plan. This data element should represent the entity billing for the service. For encounter records, if associated Type of Claim value equals 3, C, or W, then value must be the state identifier of the provider or entity
(billing or reporting) to the managed care plan. |
A unique identification number assigned by the state to a provider or capitation plan. This data element should represent the entity billing for the service. For encounter records, if associated Type of Claim value equals 3, C, or W, then value must be the state identifier of the provider or entity (billing or reporting) to the managed care plan.For sub-capitation payments, report the state-assigned provider identifier for the sub-capitated entity, when available or required. |
| 08/15/2023 |
3.12.0 |
COT.002.111 |
UPDATE |
Coding requirement |
1. Value must be associated with a populated Waiver Type (CE)2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Conditional |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Conditional |
| 08/07/2023 |
3.11.0 |
CIP.002.212 |
UPDATE |
Coding requirement |
1. Value must be in Claim Denied Indicator List (VVL)2. If value is '0', then Claim Status Category (CE) must equal "F2"3. Value must be 1 character4. Mandatory |
1. Value must be in Claim Denied Indicator List (VVL)2. If value is '0', then Claim Status Category must equal "F2"3. Value must be 1 character4. Mandatory |
| 08/28/2023 |
3.12.0 |
CRX.003.150 |
UPDATE |
Coding requirement |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is '1', then a valid value is mandatory and must be reported5. If value is in ['14', '35', '42' or '44'], then Sex (ELG.002.023) must not equals 'M'6. If XXI MBESCBES Category of Service is populated then must not be populated |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is '01', then a valid value is mandatory and must be reported5. If value is in ['14', '35', '42' or '44'], then Sex (ELG.002.023) must not equals 'M'6. If XXI MBESCBES Category of Service is populated then must not be populated |
| 08/28/2023 |
3.12.0 |
CRX.003.151 |
UPDATE |
Coding requirement |
1. Value must be in XXI MBESCBES Category of Service List (VVL)2. Conditional3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is '2', then a valid value is mandatory and must be reported4. If XIX MBESCBES Category of Service is populated then value must not be populated5. Value must be 3 characters or less |
1. Value must be in XXI MBESCBES Category of Service List (VVL)2. Conditional3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is '02', then a valid value is mandatory and must be reported4. If XIX MBESCBES Category of Service is populated then value must not be populated5. Value must be 3 characters or less |
| 08/16/2023 |
3.12.0 |
CIP.002.179 |
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.002.019) Submitting State Provider ID or4. 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 where the Provider Identifier5. Discharge Date (CIP.002.096) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or6. Discharge Date (CIP.002.096) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) |
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.002.019) Submitting State Provider ID or4. 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 where the Provider Identifier5. Discharge Date (CIP.002.096) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or6. Discharge Date (CIP.002.096) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080)7. Discharge Date (CIP.002.096) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or8. Discharge Date (CIP.002.096) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) |
| 08/28/2023 |
3.12.0 |
COT.003.212 |
UPDATE |
Coding requirement |
1. Value must be in XXI MBESCBES Category of Service List (VVL)2. Conditional3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is '2', then a valid value is mandatory and must be reported4. If XIX MBESCBES Category of Service is populated then value must not be populated5. Value must be 3 characters or less |
1. Value must be in XXI MBESCBES Category of Service List (VVL)2. Conditional3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is '02', then a valid value is mandatory and must be reported4. If XIX MBESCBES Category of Service is populated then value must not be populated5. Value must be 3 characters or less |
| 08/28/2023 |
3.12.0 |
COT.003.211 |
UPDATE |
Coding requirement |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is '1', then a valid value is mandatory and must be reported5. If value is in ['14', '35', '42' or '44'], then Sex (ELG.002.023) must not equals 'M'6. If XXI MBESCBES Category of Service is populated then must not be populated |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is '01', then a valid value is mandatory and must be reported5. If value is in ['14', '35', '42' or '44'], then Sex (ELG.002.023) must not equals 'M'6. If XXI MBESCBES Category of Service is populated then must not be populated |
| 08/07/2023 |
3.11.0 |
CLT.002.025 |
UPDATE |
Coding requirement |
1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim (CE) 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 (CE) value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory |
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. Mandatory |
| 08/07/2023 |
3.11.0 |
CIP.002.026 |
UPDATE |
Coding requirement |
1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim (CE) 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 (CE) value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory |
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. Mandatory |
| 08/07/2023 |
3.11.0 |
CLT.002.159 |
UPDATE |
Coding requirement |
1. Value must be in Claim Denied Indicator List (VVL)2. If value is '0', then Claim Status Category (CE) must equal "F2"3. Value must be 1 character4. Mandatory |
1. Value must be in Claim Denied Indicator List (VVL)2. If value is '0', then Claim Status Category must equal "F2"3. Value must be 1 character4. Mandatory |
| 08/07/2023 |
3.11.0 |
CRX.002.094 |
UPDATE |
Coding requirement |
1. Value must be in Claim Denied Indicator List (VVL)2. If value is '0', then Claim Status Category (CE) must equal "F2"3. Value must be 1 character4. Mandatory |
1. Value must be in Claim Denied Indicator List (VVL)2. If value is '0', then Claim Status Category must equal "F2"3. Value must be 1 character4. Mandatory |
| 08/16/2023 |
3.12.0 |
CLT.002.130 |
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.002.019) Submitting State Provider ID or4. 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 where the Provider Identifier5. Ending Date of Service (CLT.002.049) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or6. Ending Date of Service (CLT.002.049) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) |
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.002.019) Submitting State Provider ID or4. 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 where the Provider Identifier5. Ending Date of Service (CLT.002.049) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or6. Ending Date of Service (CLT.002.049) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080)7. Ending Date of Service (CLT.002.049) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or8. Ending Date of Service (CLT.002.049) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) |
| 08/28/2023 |
3.12.0 |
CIP.003.271 |
UPDATE |
Coding requirement |
1. Value must be in XXI MBESCBES Category of Service List (VVL)2. Conditional3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is '2', then a valid value is mandatory and must be reported4. If XIX MBESCBES Category of Service is populated then value must not be populated5. Value must be 3 characters or less |
1. Value must be in XXI MBESCBES Category of Service List (VVL)2. Conditional3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is '02', then a valid value is mandatory and must be reported4. If XIX MBESCBES Category of Service is populated then value must not be populated5. Value must be 3 characters or less |
| 08/28/2023 |
3.12.0 |
CIP.003.270 |
UPDATE |
Coding requirement |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is '1', then a valid value is mandatory and must be reported5. If value is in ['14', '35', '42' or '44'], then Sex (ELG.002.023) must not equals 'M'6. If XXI MBESCBES Category of Service is populated then must not be populated |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is '01', then a valid value is mandatory and must be reported5. If value is in ['14', '35', '42' or '44'], then Sex (ELG.002.023) must not equals 'M'6. If XXI MBESCBES Category of Service is populated then must not be populated |
| 08/07/2023 |
3.11.0 |
COT.002.025 |
UPDATE |
Coding requirement |
1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim (CE) 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 (CE) value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory |
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. Mandatory |
| 08/16/2023 |
3.12.0 |
CRX.002.070 |
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.002.019) Submitting State Provider ID or4. 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 where the Provider Identifier5. Prescription Fill Date (CRX.002.085) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or6. Prescription Fill Date (CRX.002.085) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) |
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.002.019) Submitting State Provider ID or4. 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 where the Provider Identifier Type (PRV.005.081) equal to '1' 5. When Type of Claim is in ['1','3','A','C'], then value must be populated 6. 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)7. Prescription Fill Date (CRX.002.085) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or 8. Prescription Fill Date (CRX.002.085) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) |
| 09/21/2023 |
3.13.0 |
PRV.007.100 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 09/21/2023 |
3.13.0 |
PRV.007.098 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
ELG.009.139 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
TPL.005.066 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
TPL.003.032 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
TPL.002.019 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
ELG.022.260 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
ELG.021.251 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
ELG.020.241 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
ELG.018.232 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
ELG.017.223 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
ELG.016.212 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
ELG.015.203 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
ELG.014.191 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
ELG.013.181 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
ELG.012.171 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
ELG.011.162 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
ELG.010.149 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
ELG.008.129 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
ELG.007.117 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
ELG.006.106 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
ELG.004.064 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
ELG.003.033 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
ELG.002.019 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 07/12/2023 |
3.10.0 |
CIP.002.194 |
UPDATE |
Coding requirement |
Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be populated when Outlier Code (CIP.002.197) is '01' ,'02' or '10'4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be populated when Outlier Code (CIP.002.197) is '01' ,'02' or '10'4. Conditional |
| 07/12/2023 |
3.10.0 |
CIP.002.194 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be populated, if Outlier Code (CIP.002.197) equals '00' or '09'4. Conditional |
Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be populated when Outlier Code (CIP.002.197) is '01' ,'02' or '10'4. Conditional |
| 07/12/2023 |
3.10.0 |
CRX.002.081 |
UPDATE |
Coding requirement |
1. Value must be 30 characters or less2. First five (5) characters of the value must be a Julian date express in the form YYDDD (e.g. 19095, 95th day of 20(19))3. Value must not contain a pipe or asterisk symbols4. Mandatory |
1. Value must be 30 characters or less2. Value must not contain a pipe or asterisk symbols3. Mandatory |
| 07/12/2023 |
3.10.0 |
COT.002.126 |
UPDATE |
Coding requirement |
1. Value must be 30 characters or less2. First five (5) characters of the value must be a Julian date express in the form YYDDD (e.g. 19095, 95th day of 20(19))3. Value must not contain a pipe or asterisk symbols4. Mandatory |
1. Value must be 30 characters or less2. Value must not contain a pipe or asterisk symbols3. Mandatory |
| 07/12/2023 |
3.10.0 |
CLT.002.144 |
UPDATE |
Coding requirement |
1. Value must be 30 characters or less2. First five (5) characters of the value must be a Julian date express in the form YYDDD (e.g. 19095, 95th day of 20(19))3. Value must not contain a pipe or asterisk symbols4. Mandatory |
1. Value must be 30 characters or less2. Value must not contain a pipe or asterisk symbols3. Mandatory |
| 07/12/2023 |
3.10.0 |
CIP.002.202 |
UPDATE |
Coding requirement |
1. Value must be 30 characters or less2. First five (5) characters of the value must be a Julian date express in the form YYDDD (e.g. 19095, 95th day of 20(19))3. Value must not contain a pipe or asterisk symbols4. Mandatory |
1. Value must be 30 characters or less2. Value must not contain a pipe or asterisk symbols3. Mandatory |
| 08/16/2023 |
3.12.0 |
ELG.003.040 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1, 2] or not populated3. Value must be in Citizenship Indicator List (VVL)4. If value is coded as '0', then associated Immigration Status (ELG.003.042) value must be in [ 1, 2, 3 ]5. If value is coded as '1', then associated Immigration Status (ELG.003.042) value must equal '8'6. Value must be 1 character7. Mandatory |
1. Value must be 1 character2. Value must be in Citizenship Indicator List (VVL)3. If value is coded as '0', then associated Immigration Status (ELG.003.042) value must be in [ 1, 2, 3 ]4. If value is coded as '1', then associated Immigration Status (ELG.003.042) value must equal '8'5. Mandatory |
| 08/15/2023 |
3.12.0 |
ELG.009.270 |
UPDATE |
Coding requirement |
1. Value must be 3 characters2. Conditional3. Must be a 3 digit value from the Type-of-Service valid value list |
1. Value must be 3 characters2. Conditional3. Must be a 3 digit value from the Type-of-Service (VVL) |
| 07/12/2023 |
3.10.0 |
ELG.005.097 |
UPDATE |
Coding requirement |
Value must be in Restricted Benefits Code List (VVL)2. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "05", then Eligibility Group (ELG.005.087) must be "24"3. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "06", then Eligibility Group (ELG.005.087) must be "26"4. (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "02", then Eligibility Group (ELG.005.087) must be "23"5. (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "04", then Eligibility Group (ELG.005.087) must be "25"6. (Restricted Benefits) if value is "3", then Dual Eligible Code (ELG.005.085) cannot be "00"7. Mandatory8. If value is populated, then Eligibility Group (ELG.005.087) must be populated.9. If value is "6" then Eligibility Group(ELG.DE.087) must be in ("35", "70")10. If value is "1" or "7" then Eligibility Group (EGL.DE.087) must be in ("72", "73", "74", "75") and State Plan Option Type (ELG.DE.163) must equal to "06"11. (Restricted Pregnancy-Related) if value is "4", then associated Sex (ELG.002.023) value must be "F"12. (Non-Citizen) if value is "2", then associated Citizenship Indicator (ELG.003.040) value must not be equal to "1"13. If value is "D", there must be a corresponding MFP enrollment segment (ELG00010) with Effective and End dates that are within the timespan of this segment14. Value must be 1 character15. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "01", then Eligibility Group (ELG.005.087) must be "23"16. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "03", then Eligibility Group (ELG.005.087) must be "25"17. (Restricted Benefits) if value is "G", then Dual Eligible Code (ELG.005.085) must be in (‘01’, ‘03', ‘06’) |
1. Value must be in Restricted Benefits Code List (VVL)2. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "05", then Eligibility Group (ELG.005.087) must be "24"3. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "06", then Eligibility Group (ELG.005.087) must be "26"4. (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "02", then Eligibility Group (ELG.005.087) must be "23"5. (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "04", then Eligibility Group (ELG.005.087) must be "25"6. (Restricted Benefits) if value is "3", then Dual Eligible Code (ELG.005.085) cannot be "00"7. Mandatory8. If value is populated, then Eligibility Group (ELG.005.087) must be populated.9. If value is "6" then Eligibility Group(ELG.DE.087) must be in ("35", "70")10. If value is "1" or "7" then Eligibility Group (EGL.DE.087) must be in ("72", "73", "74", "75") and State Plan Option Type (ELG.DE.163) must equal to "06"11. (Restricted Pregnancy-Related) if value is "4", then associated Sex (ELG.002.023) value must be "F"12. (Non-Citizen) if value is "2", then associated Citizenship Indicator (ELG.003.040) value must not be equal to "1"13. If value is "D", there must be a corresponding MFP enrollment segment (ELG00010) with Effective and End dates that are within the timespan of this segment14. Value must be 1 character15. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "01", then Eligibility Group (ELG.005.087) must be "23"16. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "03", then Eligibility Group (ELG.005.087) must be "25"17. (Restricted Benefits) if value is "G", then Dual Eligible Code (ELG.005.085) must be in (‘01’, ‘03', ‘06’) |
| 09/21/2023 |
3.13.0 |
PRV.009.120 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 08/09/2023 |
3.11.0 |
COT.002.113 |
UPDATE |
Definition |
The National Provider ID (NPI) of the billing entity responsible for billing a patient for healthcare services. The billing provider can also be servicing, referring, or prescribing provider. Can be admitting provider except for Long Term Care. |
The National Provider ID (NPI) of the billing entity responsible for billing a patient for healthcare services. The billing provider can also be servicing, referring, or prescribing provider. Can be admitting provider except for Long Term Care.For sub-capitation payments, report the national provider identifier (NPI) for the sub-capitated entity if the provider has one. |
| 08/16/2023 |
3.12.0 |
CLT.002.131 |
UPDATE |
Coding requirement |
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.002.081) |
1. Value must be 10 digits 2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to '2' 3. Value must exist in the NPPES NPI data file 4. Conditional 5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal '01' 6. When Type of Claim is in ['1','3','A','C'], then value must be populated 7. When Type of Claim not in ('3','C','W'), then value must match Provider Identifier (PRV.002.081) 8. NPPES Entity Type Code associated with this NPI must equal ‘2’ (Organization) |
| 08/16/2023 |
3.12.0 |
CRX.002.071 |
UPDATE |
Coding requirement |
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 not in ('3','C','W') then value must match Provider Identifier (PRV.002.081) |
1. Value must be 10 digits 2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to '2' 3. Value must exist in the NPPES NPI data file 4. Conditional 5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal '01' 6. When Type of Claim is in ['1','3','A','C'], then value must be populated 7. When Type of Claim not in ('3','C','W') then value must match Provider Identifier (PRV.002.081) 8. NPPES Entity Type Code associated with this NPI must equal ‘2’ (Organization) |
| 08/16/2023 |
3.12.0 |
CIP.002.180 |
UPDATE |
Coding requirement |
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 populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal '01' |
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 file 4. Conditional5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal '01'6. When Type of Claim is in ['1','3','A','C'], then value must be populated 7. NPPES Entity Type Code associated with this NPI must equal ‘2’ (Organization) |
| 06/02/2023 |
3.8.0 |
RULE-7247 |
ADD |
N/A |
|
Created |
| 06/02/2023 |
3.8.0 |
RULE-7251 |
ADD |
N/A |
|
Created |
| 06/02/2023 |
3.8.0 |
RULE-7250 |
ADD |
N/A |
|
Created |
| 06/02/2023 |
3.8.0 |
RULE-7249 |
ADD |
N/A |
|
Created |
| 06/02/2023 |
3.8.0 |
RULE-7248 |
ADD |
N/A |
|
Created |
| 06/02/2023 |
3.8.0 |
RULE-7246 |
ADD |
N/A |
|
Created |
| 06/02/2023 |
3.8.0 |
RULE-7245 |
ADD |
N/A |
|
Created |
| 06/02/2023 |
3.8.0 |
RULE-7244 |
ADD |
N/A |
|
Created |
| 06/02/2023 |
3.8.0 |
RULE-7243 |
ADD |
N/A |
|
Created |
| 06/02/2023 |
3.8.0 |
ALL-16-015-15 |
ADD |
N/A |
|
Created |
| 06/02/2023 |
3.8.0 |
ALL-16-014-14 |
ADD |
N/A |
|
Created |
| 06/02/2023 |
3.8.0 |
ALL-16-013-13 |
ADD |
N/A |
|
Created |
| 06/02/2023 |
3.8.0 |
ALL-16-012-12 |
ADD |
N/A |
|
Created |
| 06/02/2023 |
3.8.0 |
ALL-16-011-11 |
ADD |
N/A |
|
Created |
| 06/02/2023 |
3.8.0 |
ALL-16-010-10 |
ADD |
N/A |
|
Created |
| 06/02/2023 |
3.8.0 |
ALL-16-009-9 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
EL-3-029-38 |
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: Primary demographics on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 1, join to segment PRIMARY-DEMOGRAPHICS-ELG00002 by keeping records that satisfy the following criteria:1a. PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE <= last day of the DQ report month2a. PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE >= last day of the DQ report month OR missingOR1b. PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE is missing2b. PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE is missingSTEP 3: RESTRICTED-BENEFITS-CODE = "4"Of the MSIS IDs that meet the criteria from STEP 2, further refine the population by keeping records with RESTRICTED-BENEFITS-CODE = "4"STEP 4: SEX = "M"Of the MSIS IDs that meet the criteria from STEP 3, further refine the population by keeping records with with SEX = "M"STEP 5: Calculate percentage for measureDIVIDE the count of MSIS IDs from STEP 4 by the count of MSIS IDs from STEP 1 |
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: RESTRICTED-BENEFITS-CODE = "4"Of the MSIS IDs that meet the criteria from STEP 2, further refine the population by keeping records with RESTRICTED-BENEFITS-CODE = "4"STEP 4: Primary demographics on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 3, join to segment PRIMARY-DEMOGRAPHICS-ELG00002 by keeping records that satisfy the following criteria:1a. PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE <= last day of the DQ report month2a. PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE >= last day of the DQ report month OR missingOR1b. PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE is missing2b. PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE is missingSTEP 5: SEX = "M"Of the MSIS IDs that meet the criteria from STEP 4, further refine the population by keeping records with with SEX = "M"STEP 6: Calculate percentage for measureDIVIDE the count of MSIS IDs from STEP 5 by the count of MSIS IDs from STEP 1 |
| 06/02/2023 |
3.8.0 |
EL-3-029-38 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
EL-3-028-37 |
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: Primary demographics on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 1, join to segment PRIMARY-DEMOGRAPHICS-ELG00002 by keeping records that satisfy the following criteria:1a. PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE <= last day of the DQ report month2a. PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE >= last day of the DQ report month OR missingOR1b. PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE is missing2b. PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE is missingSTEP 3: Pregnancy Indicator = "1"Of the MSIS IDs that meet the criteria from STEP 2, further refine the population by keeping records with PREGNANCY-INDICATOR= "1" STEP 4: SEX = "M"Of the MSIS IDs that meet the criteria from STEP 3, further refine the population by keeping records with with SEX = "M"STEP 5: Calculate percentage for measureDIVIDE the count of MSIS IDs from STEP 4 by the count of MSIS IDs from STEP 1 |
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-DEMOGRAPHICS-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: Pregnancy Indicator = "1"Of the MSIS IDs that meet the criteria from STEP 2, further refine the population by keeping records with PREGNANCY-INDICATOR= "1"STEP 4: Primary demographics on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 3, join to segment PRIMARY-DEMOGRAPHICS-ELG00002 by keeping records that satisfy the following criteria:1a. PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE <= last day of the DQ report month2a. PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE >= last day of the DQ report month OR missingOR1b. PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE is missing2b. PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE is missingSTEP 5: SEX = "M"Of the MSIS IDs that meet the criteria from STEP 4, further refine the population by keeping records with with SEX = "M"STEP 6: Calculate percentage for measureDIVIDE the count of MSIS IDs from STEP 5 by the count of MSIS IDs from STEP 1 |
| 06/02/2023 |
3.8.0 |
EL-3-028-37 |
ADD |
N/A |
|
Created |
| 06/02/2023 |
3.8.0 |
EXP-13-004_1-7 |
ADD |
N/A |
|
Created |
| 06/02/2023 |
3.8.0 |
EXP-13-003_1-6 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
Data Quality Measures |
UPDATE |
Thresholds document |
212 |
250 |
| 09/06/2023 |
3.12.0 |
Data Quality Measures |
UPDATE |
Measures specification |
213 |
251 |
| 09/06/2023 |
3.12.0 |
Data Quality Measures |
UPDATE |
Threshold and measures combined |
225 |
252 |
| 09/07/2023 |
3.12.0 |
COT.003.186 |
UPDATE |
Definition |
A code to categorize the services provided to a Medicaid or CHIP enrollee. |
A code to categorize the services provided to a Medicaid or CHIP enrollee. For sub-capitation payments, report a TYPE-OF-SERVICE value 119, 120, or 122. |
| 06/02/2023 |
3.8.0 |
CIP.003.257 |
UPDATE |
Coding requirement |
1. Value must be 3 characters2. Mandatory3. Value must not equal '086' if Sex (ELG.002.023) equals 'M'4. Value must be in ['001', '058', '060', '084', '086', '090', '091', '092', '093', '123', '132', '135', '136', '137'] when associated Claim Type is CIP (Inpatient Claim) |
1. Value must be 3 characters2. Mandatory3. Value must not equal '086' if Sex (ELG.002.023) equals 'M'4. Value must be in ['001', '058', '060', '084', '086', '090', '091', '092', '093', '123', '132', '135', '136', '137'] |
| 06/02/2023 |
3.8.0 |
CRX.002.053 |
UPDATE |
Coding requirement |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Value must be populated if TYPE-OF-CLAIM <> ‘3', ‘C’, ‘W’, or '6’4. Conditional |
| 06/02/2023 |
3.8.0 |
CLT.002.076 |
UPDATE |
Coding requirement |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Value must be populated if TYPE-OF-CLAIM <> ‘3', ‘C’, ‘W’, or '6’4. Conditional |
| 08/15/2023 |
3.12.0 |
COT.002.229 |
UPDATE |
Coding requirement |
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. Conditional |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to '2'3. Conditional4. Value must exist in the NPPES NPI data file |
| 06/01/2023 |
3.8.0 |
COT.002.229 |
UPDATE |
Definition |
A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).|Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm).The NPI of Ordering Provider represents the individual who requested the service or items being reported on this service line. Example include, but are not limited to, provider ordering diagnostic tests and medical equipment or supplies.[Ordering provider information is only captured at the line level in the X12 837P format but in v3.0.0 of the T-MSIS file layout it is only captured at the header level. This discrepancy will be addressed in a future version of the T-MSIS OT file layout. Until Ordering provider information has been moved from the T-MSIS claim header to the line, there is no need to report it at the header.] |
The NPI of Ordering Provider represents the individual who requested the service or items being reported on this service line. Example include, but are not limited to, provider ordering diagnostic tests and medical equipment or supplies.[Ordering provider information is only captured at the line level in the X12 837P format but in v3.0.0 of the T-MSIS file layout it is only captured at the header level. This discrepancy will be addressed in a future version of the T-MSIS OT file layout. Until Ordering provider information has been moved from the T-MSIS claim header to the line, there is no need to report it at the header.] |
| 06/02/2023 |
3.8.0 |
CRX.002.054 |
UPDATE |
Coding requirement |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Value must be populated if TYPE-OF-CLAIM <> ‘3', ‘C’, ‘W’, or '6’4. Conditional |
| 06/02/2023 |
3.8.0 |
COT.002.063 |
UPDATE |
Coding requirement |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Value must be populated if TYPE-OF-CLAIM <> ‘3', ‘C’, ‘W’, or '6’4. Conditional |
| 06/02/2023 |
3.8.0 |
CLT.002.077 |
UPDATE |
Coding requirement |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Value must be populated if TYPE-OF-CLAIM <> ‘3', ‘C’, ‘W’, or '6’4. Conditional |
| 06/02/2023 |
3.8.0 |
CIP.002.127 |
UPDATE |
Coding requirement |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Value must be populated if TYPE-OF-CLAIM <> ‘3', ‘C’, ‘W’, or '6’4. Conditional |
| 06/02/2023 |
3.8.0 |
CRX.002.053 |
UPDATE |
Coding requirement |
Value must be in Funding Code List (VVL)2. Value must be 1 character3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
| 06/02/2023 |
3.8.0 |
COT.002.062 |
UPDATE |
Coding requirement |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Value must be populated if TYPE-OF-CLAIM <> ‘3', ‘C’, ‘W’, or '6’4. Conditional |
| 06/02/2023 |
3.8.0 |
CLT.002.076 |
UPDATE |
Coding requirement |
Value must be in Funding Code List (VVL)2. Value must be 1 character3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
| 06/02/2023 |
3.8.0 |
CIP.002.126 |
UPDATE |
Coding requirement |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Value must be populated if TYPE-OF-CLAIM <> ‘3', ‘C’, ‘W’, or '6’4. Conditional |
| 06/02/2023 |
3.8.0 |
CRX.003.134 |
UPDATE |
Coding requirement |
1. Value must be 3 characters2. Mandatory3. Value must be in ['011', '018', '033', '034', '036', '085', '089', '127', '131', '136', '137', '145'] when associated Claim Type is CRX (RX Claim) |
1. Value must be 3 characters2. Mandatory3. Value must be in ['011', '018', '033', '034', '036', '085', '089', '127', '131', '136', '137', '145'] |
| 06/02/2023 |
3.8.0 |
COT.003.186 |
UPDATE |
Coding requirement |
1. Value must be 3 characters2. Mandatory3. When value is in [119-122], Servicing Provider NPI Num (COT.002.190) should not be populated4. Value must be in ['002', '003', '004', '005', '006', '007', '008', '010', '011', '012', '013', '014', '015', '016', '017', '018', '019', '020', '021', '022', '023', '024', '025', '026', '027', '028', '029', '030', '031', '032', '035', '036', '037', '038', '039', '040', '041', '042', '043', '049', '050', '051', '052', '053', '054', '055', '056', '057', '058', '060', '061', '062', '063', '064', '065', '066', '067', '068', '069', '070', '071', '072', '073', '074', '075', '076', '077', '078', '079', '080', '081', '082', '083', '084', '085', '086', '087', '088', '089', '115', '119', '120', '121', '122', '127', '131', '134', '135', '136', '137', '138', '139', '140', '141', '142', '143', '144', '145', '147'] when associated Claim Type is COT (Other Claim)5. When value is in [119-122], Servicing Provider Taxonomy (COT.003.191) should not be populated6. When value is in [119-122], Referring Provider NPI Num (COT.002.118) should not be populated7. Value must be 3 characters8. Mandatory9. When value is in [119-122], Billing Provider NPI Num (COT.002.113) should not be populated10. When value is in [119-122], Billing Provider Taxonomy (COT.002.114) should not be populated11. When value is in [119-122], Referring Provider Taxonomy (COT.002.119) should not be populated12. When value is not in ['025','085'], Sex (ELG.002.023) equals 'M'13. When value is in [119-122], Servicing Provider Num (COT.002.189) should not be populated |
1. Value must be 3 characters2. Mandatory3. When value is in [119-122], Servicing Provider NPI Num (COT.002.190) should not be populated4. Value must be in ['002', '003', '004', '005', '006', '007', '008', '010', '011', '012', '013', '014', '015', '016', '017', '018', '019', '020', '021', '022', '023', '024', '025', '026', '027', '028', '029', '030', '031', '032', '035', '036', '037', '038', '039', '040', '041', '042', '043', '049', '050', '051', '052', '053', '054', '055', '056', '057', '058', '060', '061', '062', '063', '064', '065', '066', '067', '068', '069', '070', '071', '072', '073', '074', '075', '076', '077', '078', '079', '080', '081', '082', '083', '084', '085', '086', '087', '088', '089', '115', '119', '120', '121', '122', '127', '131', '134', '135', '136', '137', '138', '139', '140', '141', '142', '143', '144', '145', '147']5. When value is in [119-122], Servicing Provider Taxonomy (COT.003.191) should not be populated6. When value is in [119-122], Referring Provider NPI Num (COT.002.118) should not be populated7. Value must be 3 characters8. Mandatory9. When value is in [119-122], Billing Provider NPI Num (COT.002.113) should not be populated10. When value is in [119-122], Billing Provider Taxonomy (COT.002.114) should not be populated11. When value is in [119-122], Referring Provider Taxonomy (COT.002.119) should not be populated12. When value is not in ['025','085'], Sex (ELG.002.023) equals 'M'13. When value is in [119-122], Servicing Provider Num (COT.002.189) should not be populated |
| 06/02/2023 |
3.8.0 |
CLT.003.211 |
UPDATE |
Coding requirement |
1. Value must be 3 characters2. Mandatory3. Value must be in ['009', '044', '045', '046', '047', '048', '050', '059', '133', '136', '137', '146', '147'] when associated Claim Type is CLT (Long Term Claim) |
1. Value must be 3 characters2. Mandatory3. Value must be in ['009', '044', '045', '046', '047', '048', '050', '059', '133', '136', '137', '146', '147'] |
| 06/02/2023 |
3.8.0 |
CIP.003.257 |
UPDATE |
Coding requirement |
Value must be 3 characters2. Mandatory3. Value must not equal '086' if Sex (ELG.002.023) equals 'M'4. Value must be in ['001', '058', '060', '084', '086', '090', '091', '092', '093', '123', '132', '135', '136', '137'] when associated Claim Type is CIP (Inpatient Claim) |
1. Value must be 3 characters2. Mandatory3. Value must not equal '086' if Sex (ELG.002.023) equals 'M'4. Value must be in ['001', '058', '060', '084', '086', '090', '091', '092', '093', '123', '132', '135', '136', '137'] when associated Claim Type is CIP (Inpatient Claim) |
| 06/01/2023 |
3.8.0 |
CRX.002.053 |
UPDATE |
Coding requirement |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Conditional |
Value must be in Funding Code List (VVL)2. Value must be 1 character3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
| 06/01/2023 |
3.8.0 |
COT.002.062 |
UPDATE |
Coding requirement |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Conditional |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
| 06/01/2023 |
3.8.0 |
CLT.002.076 |
UPDATE |
Coding requirement |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Conditional |
Value must be in Funding Code List (VVL)2. Value must be 1 character3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
| 05/31/2023 |
3.8.0 |
CLT.002.076 |
UPDATE |
Coding requirement |
Value must be in Funding Code List (VVL)2. Value must be 1 character3. Conditional |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Conditional |
| 06/01/2023 |
3.8.0 |
CIP.002.126 |
UPDATE |
Coding requirement |
Value must be in Funding Code List (VVL)2. Value must be 1 character3. Conditional |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
| 09/01/2023 |
3.12.0 |
CRX.003.129 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is "0", then the Medicare Paid Amount must not be populated.4. Conditional5. If value is populated, Crossover Indicator must be equal to "1" |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is "0", then the value must not be populated.4. Conditional5. If value is populated, Crossover Indicator must be equal to "1" |
| 08/28/2023 |
3.12.0 |
CRX.002.043 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated.4. (Medicare Enrolled) if associated Dual Eligible Code (ELG.005.085) value is in ["01", "02", "03", "04", "05", "06", "08", "09", or "10"], then value is mandatory and must be provided5. Conditional6. When populated, value must be less than or equal to Total Billed Amount |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated.4. Conditional5. When populated, value must be less than or equal to Total Billed Amount |
| 09/01/2023 |
3.12.0 |
COT.003.182 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is "0", then the Medicare Paid Amount must not be populated.4. Conditional5. If value is populated, Crossover Indicator must be equal to "1" |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is "0", then the value must not be populated.4. Conditional5. If value is populated, Crossover Indicator must be equal to "1" |
| 08/28/2023 |
3.12.0 |
COT.002.052 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated.4. (Medicare Enrolled) if associated Dual Eligible Code (ELG.005.085) value is in ["01", "02", "03", "04", "05", "06", "08", "09", or "10"], then value is mandatory and must be provided5. Conditional6. When populated, value must be less than or equal to Total Billed Amount |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated.4. Conditional5. When populated, value must be less than or equal to Total Billed Amount |
| 09/01/2023 |
3.12.0 |
CLT.002.179 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is "0", then the Medicare Paid Amount must not be populated.4. Conditional5. If value is populated, Crossover Indicator must be equal to "1" |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is "0", then the value must not be populated.4. Conditional5. If value is populated, Crossover Indicator must be equal to "1" |
| 08/28/2023 |
3.12.0 |
CLT.002.067 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated.4. (Medicare Enrolled) if associated Dual Eligible Code (ELG.005.085) value is in ["01", "02", "03", "04", "05", "06", "08", "09", or "10"], then value is mandatory and must be provided5. Conditional6. When populated, value must be less than or equal to Total Billed Amount |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated.4. Conditional5. When populated, value must be less than or equal to Total Billed Amount |
| 09/01/2023 |
3.12.0 |
CIP.002.228 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is "0", then the Medicare Paid Amount must not be populated.4. Conditional5. If value is populated, Crossover Indicator must be equal to "1" |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is "0", then the value must not be populated.4. Conditional5. If value is populated, Crossover Indicator must be equal to "1" |
| 05/31/2023 |
3.8.0 |
CLT.003.211 |
UPDATE |
Coding requirement |
1. Value must be 3 characters2. Mandatory3. Value must satisfy the requirements of Type of Service (Long Term Claim) List (VVL) |
1. Value must be 3 characters2. Mandatory3. Value must be in ['009', '044', '045', '046', '047', '048', '050', '059', '133', '136', '137', '146', '147'] when associated Claim Type is CLT (Long Term Claim) |
| 07/13/2023 |
3.10.0 |
CRX.002.022 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less5. The Prescription Fill Date (CRX.002.085) on the claim must fall between Enrollment Timespan Effective Date (ELG.021.253) and Enrollment Timespan End Date (ELG.021.253) |
1. Mandatory2. Value must be 20 characters or less3. The Prescription Fill Date (CRX.002.085) on the claim must fall between Enrollment Timespan Effective Date (ELG.021.253) and Enrollment Timespan End Date (ELG.021.253) |
| 09/21/2023 |
3.13.0 |
ELG.004.062 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 05/31/2023 |
3.8.0 |
COT.003.186 |
UPDATE |
Coding requirement |
1. Value must be 3 characters2. Mandatory3. When value is in [119-122], Servicing Provider NPI Num (COT.002.190) should not be populated4. Value must satisfy the requirements of Type of Service (Other Claim) List (VVL)5. When value is in [119-122], Servicing Provider Taxonomy (COT.003.191) should not be populated6. When value is in [119-122], Referring Provider NPI Num (COT.002.118) should not be populated7. Value must be 3 characters8. Mandatory9. When value is in [119-122], Billing Provider NPI Num (COT.002.113) should not be populated10. When value is in [119-122], Billing Provider Taxonomy (COT.002.114) should not be populated11. When value is in [119-122], Referring Provider Taxonomy (COT.002.119) should not be populated12. When value is not in ['025','085'], Sex (ELG.002.023) equals 'M'13. When value is in [119-122], Servicing Provider Num (COT.002.189) should not be populated |
1. Value must be 3 characters2. Mandatory3. When value is in [119-122], Servicing Provider NPI Num (COT.002.190) should not be populated4. Value must be in ['002', '003', '004', '005', '006', '007', '008', '010', '011', '012', '013', '014', '015', '016', '017', '018', '019', '020', '021', '022', '023', '024', '025', '026', '027', '028', '029', '030', '031', '032', '035', '036', '037', '038', '039', '040', '041', '042', '043', '049', '050', '051', '052', '053', '054', '055', '056', '057', '058', '060', '061', '062', '063', '064', '065', '066', '067', '068', '069', '070', '071', '072', '073', '074', '075', '076', '077', '078', '079', '080', '081', '082', '083', '084', '085', '086', '087', '088', '089', '115', '119', '120', '121', '122', '127', '131', '134', '135', '136', '137', '138', '139', '140', '141', '142', '143', '144', '145', '147'] when associated Claim Type is COT (Other Claim)5. When value is in [119-122], Servicing Provider Taxonomy (COT.003.191) should not be populated6. When value is in [119-122], Referring Provider NPI Num (COT.002.118) should not be populated7. Value must be 3 characters8. Mandatory9. When value is in [119-122], Billing Provider NPI Num (COT.002.113) should not be populated10. When value is in [119-122], Billing Provider Taxonomy (COT.002.114) should not be populated11. When value is in [119-122], Referring Provider Taxonomy (COT.002.119) should not be populated12. When value is not in ['025','085'], Sex (ELG.002.023) equals 'M'13. When value is in [119-122], Servicing Provider Num (COT.002.189) should not be populated |
| 07/13/2023 |
3.10.0 |
CLT.002.022 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less5. Populated value must begin with an '&', when TYPE-OF-CLAIM = 4, D or X (lump sum payment)6. The Beginning Date of Service on the claim must fall between (ELG.021.253) enrollment effective and (ELG.021.253) end date |
1. Mandatory2. Value must be 20 characters or less3. Populated value must begin with an '&', when TYPE-OF-CLAIM = 4, D or X (lump sum payment)4. The Beginning Date of Service on the claim must fall between (ELG.021.253) enrollment effective and (ELG.021.253) end date |
| 07/13/2023 |
3.10.0 |
CIP.002.022 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less5. When Type of Claim not in (4, D, X, Z, U, V, Y, W), value must match MSIS Identification Number (ELG.021.251) and the Admission Date (CIP.002.094) must be between Enrollment Effective Date (ELG.021.253) and Enrollment End Date (ELG.021.254)6. When Type of Claim (CIP.002.100) equals 4, D or X (lump sum payment) value must begin with an '&' |
1. Mandatory2. Value must be 20 characters or less3. When Type of Claim not in (4, D, X, Z, U, V, Y, W), value must match MSIS Identification Number (ELG.021.251) and the Admission Date (CIP.002.094) must be between Enrollment Effective Date (ELG.021.253) and Enrollment End Date (ELG.021.254)4. When Type of Claim (CIP.002.100) equals 4, D or X (lump sum payment) value must begin with an '&' |
| 07/13/2023 |
3.10.0 |
COT.002.022 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less5. Populated value must begin with an '&', when Type of Claim (COT.002.037) = 4, D or X (lump sum payment)6. Value must match MSIS Identification Number (ELG.021.251) and the Beginning Date of Service (COT.002.033) must be between Enrollment Effective Date (ELG.021.253) and Enrollment End Date (ELG.021.254) |
1. Mandatory2. Value must be 20 characters or less3. Populated value must begin with an '&', when Type of Claim (COT.002.037) = 4, D or X (lump sum payment)4. Value must match MSIS Identification Number (ELG.021.251) and the Beginning Date of Service (COT.002.033) must be between Enrollment Effective Date (ELG.021.253) and Enrollment End Date (ELG.021.254) |
| 05/31/2023 |
3.8.0 |
CIP.003.257 |
UPDATE |
Coding requirement |
1. Value must be 3 characters2. Mandatory3. Value must not equal '086' if Sex (ELG.002.023) equals 'M'4. Value must satisfy the requirements of Type of Service (Inpatient Claim) List (VVL) |
Value must be 3 characters2. Mandatory3. Value must not equal '086' if Sex (ELG.002.023) equals 'M'4. Value must be in ['001', '058', '060', '084', '086', '090', '091', '092', '093', '123', '132', '135', '136', '137'] when associated Claim Type is CIP (Inpatient Claim) |
| 06/01/2023 |
3.8.0 |
CRX.003.134 |
UPDATE |
Coding requirement |
1. Value must be 3 characters2. Mandatory3. Value must satisfy the requirements of Type of Service (RX Claim) List (VVL) |
1. Value must be 3 characters2. Mandatory3. Value must be in ['011', '018', '033', '034', '036', '085', '089', '127', '131', '136', '137', '145'] when associated Claim Type is CRX (RX Claim) |
| 07/14/2023 |
3.10.0 |
ELG.003.038 |
UPDATE |
Definition |
A code indicating the family income level. |
A code indicating the federal poverty level range in which the family income falls.If the beneficiary's income was assessed using multiple methodologies (MAGI and Non-MAGI), report the income that applies to their primary eligibility group.A beneficiary’s income is applicable unless it is not required by the eligibility group for which they were determined eligible. For example, the eligibility groups for children with adoption assistance, foster care, or guardianship care under title IV-E and optional eligibility for individuals needing treatment for breast or cervical cancer do not have a Medicaid income test. Additionally, for individuals receiving SSI, states with section 1634 agreements with the Social Security Administration (SSA) and states that use SSI financial methodologies for Medicaid determinations do not conduct separate Medicaid financial eligibility for this group. |
| 08/09/2023 |
3.11.0 |
MCR.002.020 |
UPDATE |
Definition |
The first calendar day on which all of the other data elements in the same segment were effective. |
The start date of the managed care contract period with the state. |
| 09/21/2023 |
3.13.0 |
ELG.014.196 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 08/07/2023 |
3.11.0 |
CIP.003.239 |
UPDATE |
Coding requirement |
1. Value must be in Line Adjustment Indicator List (VVL)2. If associated Type of Claim (CE) 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 (CE) value is in [ 4, D, X ], then value must be in [5, 6]4. Value must be 1 character5. Conditional6. If associated Line Adjustment Number is populated, then value must be populated |
1. Value must be in Line 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. Conditional6. If associated Line Adjustment Number is populated, then value must be populated |
| 08/07/2023 |
3.11.0 |
CRX.003.116 |
UPDATE |
Coding requirement |
1. Value must be in Line Adjustment Indicator List (VVL)2. If associated Type of Claim (CE) 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 (CE) value is in [ 4, D, X ], then value must be in [5, 6]4. Value must be 1 character5. Conditional6. If associated Line Adjustment Number is populated, then value must be populated |
1. Value must be in Line 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. Conditional6. If associated Line Adjustment Number is populated, then value must be populated |
| 08/07/2023 |
3.11.0 |
CLT.003.192 |
UPDATE |
Coding requirement |
1. Value must be in Line Adjustment Indicator List (VVL)2. If associated Type of Claim (CE) 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 (CE) value is in [ 4, D, X ], then value must be in [5, 6]4. Value must be 1 character5. Conditional6. If associated Line Adjustment Number is populated, then value must be populated |
1. Value must be in Line 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. Conditional6. If associated Line Adjustment Number is populated, then value must be populated |
| 08/07/2023 |
3.11.0 |
COT.003.162 |
UPDATE |
Coding requirement |
1. Value must be in Line Adjustment Indicator List (VVL)2. If associated Type of Claim (CE) 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 (CE) value is in [ 4, D, X ], then value must be in [5, 6]4. Value must be 1 character5. Conditional6. If associated Line Adjustment Number is populated, then value must be populated |
1. Value must be in Line 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. Conditional6. If associated Line Adjustment Number is populated, then value must be populated |
| 04/21/2023 |
3.6.0 |
RULE-7427 |
ADD |
N/A |
|
Created |
| 04/21/2023 |
3.6.0 |
RULE-7540 |
ADD |
N/A |
|
Created |
| 04/21/2023 |
3.6.0 |
RULE-7539 |
ADD |
N/A |
|
Created |
| 04/21/2023 |
3.6.0 |
RULE-7538 |
ADD |
N/A |
|
Created |
| 04/21/2023 |
3.6.0 |
RULE-7781 |
ADD |
N/A |
|
Created |
| 04/21/2023 |
3.6.0 |
RULE-7780 |
ADD |
N/A |
|
Created |
| 04/21/2023 |
3.6.0 |
RULE-7779 |
ADD |
N/A |
|
Created |
| 04/21/2023 |
3.6.0 |
RULE-7778 |
ADD |
N/A |
|
Created |
| 04/21/2023 |
3.6.0 |
RULE-7777 |
ADD |
N/A |
|
Created |
| 04/21/2023 |
3.6.0 |
RULE-7776 |
ADD |
N/A |
|
Created |
| 04/21/2023 |
3.6.0 |
RULE-7775 |
ADD |
N/A |
|
Created |
| 04/21/2023 |
3.6.0 |
RULE-7774 |
ADD |
N/A |
|
Created |
| 04/21/2023 |
3.6.0 |
RULE-7666 |
ADD |
N/A |
|
Created |
| 04/21/2023 |
3.6.0 |
RULE-7665 |
ADD |
N/A |
|
Created |
| 04/21/2023 |
3.6.0 |
RULE-7664 |
ADD |
N/A |
|
Created |
| 04/21/2023 |
3.6.0 |
RULE-7663 |
ADD |
N/A |
|
Created |
| 04/21/2023 |
3.6.0 |
RULE-7662 |
ADD |
N/A |
|
Created |
| 04/21/2023 |
3.6.0 |
RULE-7735 |
ADD |
N/A |
|
Created |
| 04/21/2023 |
3.6.0 |
RULE-7734 |
ADD |
N/A |
|
Created |
| 04/21/2023 |
3.6.0 |
RULE-7733 |
ADD |
N/A |
|
Created |
| 04/21/2023 |
3.6.0 |
RULE-7732 |
ADD |
N/A |
|
Created |
| 04/21/2023 |
3.6.0 |
RULE-7731 |
ADD |
N/A |
|
Created |
| 04/21/2023 |
3.6.0 |
RULE-7729 |
ADD |
N/A |
|
Created |
| 04/21/2023 |
3.6.0 |
RULE-7728 |
ADD |
N/A |
|
Created |
| 04/21/2023 |
3.6.0 |
RULE-7706 |
ADD |
N/A |
|
Created |
| 04/21/2023 |
3.6.0 |
RULE-7702 |
ADD |
N/A |
|
Created |
| 04/21/2023 |
3.6.0 |
RULE-7182 |
ADD |
N/A |
|
Created |
| 04/21/2023 |
3.6.0 |
MCR-9-019-21 |
ADD |
N/A |
|
Created |
| 04/21/2023 |
3.6.0 |
MCR-13-019-21 |
ADD |
N/A |
|
Created |
| 04/21/2023 |
3.6.0 |
MCR-9-018-20 |
ADD |
N/A |
|
Created |
| 04/21/2023 |
3.6.0 |
MCR-13-018-20 |
ADD |
N/A |
|
Created |
| 04/21/2023 |
3.6.0 |
EL-20-001-1 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
EXP-39-001_1-2 |
UPDATE |
Priority |
N/A |
High |
| 09/06/2023 |
3.12.0 |
EXP-39-001_1-2 |
UPDATE |
For ta comprehensive |
No |
TA- Inferential |
| 09/06/2023 |
3.12.0 |
EXP-39-001_1-2 |
UPDATE |
For ta inferential |
No |
Yes |
| 09/06/2023 |
3.12.0 |
EXP-39-001_1-2 |
UPDATE |
Ta min |
|
0 |
| 09/06/2023 |
3.12.0 |
EXP-39-001_1-2 |
UPDATE |
Ta max |
|
0.3 |
| 09/06/2023 |
3.12.0 |
EXP-39-001_1-2 |
UPDATE |
Threshold minimum |
TBD |
0 |
| 09/06/2023 |
3.12.0 |
EXP-39-001_1-2 |
UPDATE |
Threshold maximum |
TBD |
0.3 |
| 09/06/2023 |
3.12.0 |
EXP-37-001_1-2 |
UPDATE |
Priority |
N/A |
High |
| 09/06/2023 |
3.12.0 |
EXP-37-001_1-2 |
UPDATE |
For ta comprehensive |
No |
TA- Inferential |
| 09/06/2023 |
3.12.0 |
EXP-37-001_1-2 |
UPDATE |
For ta inferential |
No |
Yes |
| 09/06/2023 |
3.12.0 |
EXP-37-001_1-2 |
UPDATE |
Ta min |
|
0 |
| 09/06/2023 |
3.12.0 |
EXP-37-001_1-2 |
UPDATE |
Ta max |
|
0.3 |
| 09/06/2023 |
3.12.0 |
EXP-37-001_1-2 |
UPDATE |
Threshold minimum |
TBD |
0 |
| 09/06/2023 |
3.12.0 |
EXP-37-001_1-2 |
UPDATE |
Threshold maximum |
TBD |
0.3 |
| 09/06/2023 |
3.12.0 |
RULE-7569 |
UPDATE |
Measure name |
% of Submitting State Provider IDs (FACILITY-GROUP-INDIVIDUAL-CODE = 03) with more than one NPI (PROV-IDENTIFIER-TYPE = 2) (across all time) |
% of Provider Attributes Main segments for individual providers (FACILITY-GROUP-INDIVIDUAL-CODE = 03) with more than one NPI (PROV-IDENTIFIER-TYPE = 2) (across all time) |
| 06/02/2023 |
3.8.0 |
MCR-64-004_1-8 |
UPDATE |
Priority |
High |
Medium |
| 06/02/2023 |
3.8.0 |
MCR-64-003_1-7 |
UPDATE |
Priority |
High |
Medium |
| 06/02/2023 |
3.8.0 |
MCR-64-002_1-6 |
UPDATE |
Priority |
High |
Medium |
| 06/02/2023 |
3.8.0 |
MCR-64-001_1-5 |
UPDATE |
Priority |
High |
Medium |
| 09/06/2023 |
3.12.0 |
EL-6-036-36 |
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: 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: Dual eligiblesOf the MSIS IDs which meet the criteria from STEP 2, restrict to dual eligibles:1. DUAL-ELIGIBLE-CODE equals ("01" or "02" or "03" or "04" or "05" or "06" or "08" or "09" or "10")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: Medicare Beneficiary Identifier is missingOf the MSIS IDs that meet the criteria from STEP 4, further refine the population by keeping MSIS IDs where:1. MEDICARE-BENEFICIARY-IDENTIFIER is missingSTEP 6: Calculate percentageDivide the count of unique MSIS IDs from STEP 5 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: 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: Dual eligiblesOf the MSIS IDs which meet the criteria from STEP 2, restrict to dual eligibles:1. DUAL-ELIGIBLE-CODE equals ("01" or "02" or "03" or "04" or "05" or "06" or "08" or "09" or "10")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: Medicare Beneficiary Identifier is missingOf the MSIS IDs that meet the criteria from STEP 4, further refine the population by keeping MSIS IDs where:1. MEDICARE-BENEFICIARY-IDENTIFIER is missingSTEP 6: Calculate percentageDivide the count of unique MSIS IDs from STEP 5 by the count of unique MSIS IDs from STEP 4 |
| 09/06/2023 |
3.12.0 |
MIS-86-020-20 |
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-86-002-2 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) |
STEP 1: Active non-duplicate RX claims during DQ 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 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-86-002-2 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) |
| 09/06/2023 |
3.12.0 |
MIS-86-018-18 |
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-86-002-2 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) |
STEP 1: Active non-duplicate RX claims during DQ 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 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-86-002-2 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) |
| 09/06/2023 |
3.12.0 |
MIS-86-015-15 |
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-86-002-2 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) |
STEP 1: Active non-duplicate RX claims during DQ 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 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-86-002-2 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) |
| 09/06/2023 |
3.12.0 |
MIS-86-014-14 |
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-86-002-2 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) |
STEP 1: Active non-duplicate RX claims during DQ 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 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-86-002-2 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) |
| 09/06/2023 |
3.12.0 |
MIS-86-003-3 |
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 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-86-002-2 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) |
STEP 1: Active non-duplicate RX claims during DQ 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 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-86-002-2 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) |
| 09/06/2023 |
3.12.0 |
MIS-86-002-2 |
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-86-002-2 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) |
STEP 1: Active non-duplicate RX claims during DQ 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 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-86-002-2 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) |
| 09/06/2023 |
3.12.0 |
MCR-59-003-15 |
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 Encounter: Original, 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" STEP 3: Exclude sub-capitation encountersOf 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: Exclude childless headersOf the claim headers that meet the criteria from STEP 3, drop all headers that do not merge to at least one lineSTEP 5: Claims paid at the line levelOf claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. PAYMENT-LEVEL-IND = "2"STEP 6: Sum Medicaid paid amount from the claim linesOf the claim lines that meet the criteria from STEP 3, sum the MEDICAID-PAID-AMT values to the header level**Note: Missing values are converted to 0 before calculating the sumSTEP 7: Sum does not match total Medicaid paid amountKeep the claims where the sum from STEP 6 does NOT equal the TOT-MEDICAID-PAID-AMT from the header record**Note: Missing values are converted to 0 before comparisonSTEP 8: Calculate the percentage for the measureDivide the count of header claims from STEP 7 by the count of header claims from STEP 5. |
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 Encounter: Original, 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" STEP 3: Exclude sub-capitation encountersOf 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: Exclude childless headersOf the claim headers that meet the criteria from STEP 3, drop all headers that do not merge to at least one lineSTEP 5: Claims paid at the line levelOf claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. PAYMENT-LEVEL-IND = "2"STEP 6: Sum Medicaid paid amount from the claim linesOf the claim lines that meet the criteria from STEP 5, sum the MEDICAID-PAID-AMT values to the header level**Note: Missing values are converted to 0 before calculating the sumSTEP 7: Sum does not match total Medicaid paid amountKeep the claims where the sum from STEP 6 does NOT equal the TOT-MEDICAID-PAID-AMT from the header record**Note: Missing values are converted to 0 before comparisonSTEP 8: Calculate the percentage for the measureDivide the count of header claims from STEP 7 by the count of header claims from STEP 5. |
| 09/06/2023 |
3.12.0 |
MCR-59-002-14 |
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 Encounter: Original, 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" STEP 3: Exclude sub-capitation encountersOf 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: Exclude childless headersOf the claim headers that meet the criteria from STEP 3, drop all headers that do not merge to at least one lineSTEP 5: Claims paid at the line levelOf claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. PAYMENT-LEVEL-IND = "2"STEP 6: Sum Medicaid paid amount from the claim linesOf the claim lines that meet the criteria from STEP 3, sum the MEDICAID-PAID-AMT values to the header level**Note: Missing values are converted to 0 before calculating the sumSTEP 7: Sum does not match total Medicaid paid amountKeep the claims where the sum from STEP 6 does NOT equal the TOT-MEDICAID-PAID-AMT from the header record**Note: Missing values are converted to 0 before comparisonSTEP 8: Calculate the percentage for the measureDivide the count of header claims from STEP 7 by the count of header claims from STEP 5. |
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 Encounter: Original, 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" STEP 3: Exclude sub-capitation encountersOf 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: Exclude childless headersOf the claim headers that meet the criteria from STEP 3, drop all headers that do not merge to at least one lineSTEP 5: Claims paid at the line levelOf claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. PAYMENT-LEVEL-IND = "2"STEP 6: Sum Medicaid paid amount from the claim linesOf the claim lines that meet the criteria from STEP 5, sum the MEDICAID-PAID-AMT values to the header level**Note: Missing values are converted to 0 before calculating the sumSTEP 7: Sum does not match total Medicaid paid amountKeep the claims where the sum from STEP 6 does NOT equal the TOT-MEDICAID-PAID-AMT from the header record**Note: Missing values are converted to 0 before comparisonSTEP 8: Calculate the percentage for the measureDivide the count of header claims from STEP 7 by the count of header claims from STEP 5. |
| 06/02/2023 |
3.8.0 |
ALL-13-003-5 |
UPDATE |
Specification |
STEP 1: Active non-duplicate IP records during DQ report monthDefine the IP 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: Medicaid FFS and Encounter: 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 "3"2. ADJUSTMENT_IND = "0"STEP 3: Non-missing beginning date of serviceOf the claims that meet the criteria from STEP 2, restrict to non-missing ADMISSION-DATESTEP 4: Link claims to enrollment time spanKeep all claims from STEP 3 for which the MSIS ID on the claim is also found on an ENROLLMENT-TIME-SPAN-ELG00021 segmentSTEP 5: Alien during date of serviceLink MSIS-IDs from the claims in STEP 4 to the ELIGIBILITY-DETERMINANTS-ELG00005 file segment and keep segments that satisfy the following criteria:1. PRIMARY-ELIGIBILITY-GROUP-IND = 12. RESTRICTED-BENEFIT-CODE = "2"3. Claims ADMISSION-DATE>= ELIGIBILITY-DETERMINANT-EFF-DATE4. Claims ADMISSION-DATE <= ELIGIBILITY-DETERMINANT-END-DATE OR ELIGIBILITY-DETERMINANT-END-DATE is missingSTEP 6: Unique MSIS-IDs in claimsOf the claims that meet the criteria from STEP 5, limit to unique MSIS-IDsSTEP 7: Non-emergency room and non-pregnancy related servicesOf the claims that meet the criteria from STEP 5, restrict to claims with that do NOT have emergency room revenue codes or pregnancy-related diagnosis codes or procedure codes:NOT (1a. REVENUE-CODE equal to ("450", "451", "452", "453", "454", "455", "456", "457", "458", "459", "0450", "0451", "0452", "0453", "0454", "0455", "0456", "0457", "0458", "0459" ,“0981”,“0720”, “0721”, “0722”, “0723”, “0724”, “0729”)OR2a. DIAGNOSIS-CODE-1 through DIAGNOSIS-CODE-12 is found in the Pregnancy CodeSet tab for ICD-10-CM code typesOR3a. PROCEDURE-CODE-1 through PROCEDURE-CODE-6 is found in the Pregnancy CodeSet tab for ICD-10-PCM code types)STEP 8: Calculate percentageDivide the count of unique MSIS-IDs from STEP 7 by the count of MSIS-IDs from STEP 6 |
STEP 1: Active non-duplicate IP records during DQ report monthDefine the IP 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: Medicaid FFS and Encounter: 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 "3"2. ADJUSTMENT_IND = "0"STEP 3: Non-missing admission dateOf the claims that meet the criteria from STEP 2, restrict to non-missing ADMISSION-DATESTEP 4: Link claims to enrollment time spanKeep all claims from STEP 3 for which the MSIS ID on the claim is also found on an ENROLLMENT-TIME-SPAN-ELG00021 segmentSTEP 5: Alien during date of serviceLink MSIS-IDs from the claims in STEP 4 to the ELIGIBILITY-DETERMINANTS-ELG00005 file segment and keep segments that satisfy the following criteria:1. PRIMARY-ELIGIBILITY-GROUP-IND = 12. RESTRICTED-BENEFIT-CODE = "2"3. Claims ADMISSION-DATE>= ELIGIBILITY-DETERMINANT-EFF-DATE4. Claims ADMISSION-DATE <= ELIGIBILITY-DETERMINANT-END-DATE OR ELIGIBILITY-DETERMINANT-END-DATE is missingSTEP 6: Unique MSIS-IDs in claimsOf the claims that meet the criteria from STEP 5, limit to unique MSIS-IDsSTEP 7: Non-emergency room and non-pregnancy related servicesOf the claims that meet the criteria from STEP 5, restrict to claims with that do NOT have emergency room revenue codes or pregnancy-related diagnosis codes or procedure codes:NOT (1a. REVENUE-CODE equal to ("450", "451", "452", "453", "454", "455", "456", "457", "458", "459", "0450", "0451", "0452", "0453", "0454", "0455", "0456", "0457", "0458", "0459" ,“0981”,“0720”, “0721”, “0722”, “0723”, “0724”, “0729”)OR2a. DIAGNOSIS-CODE-1 through DIAGNOSIS-CODE-12 is found in the Pregnancy CodeSet tab for ICD-10-CM code typesOR3a. PROCEDURE-CODE-1 through PROCEDURE-CODE-6 is found in the Pregnancy CodeSet tab for ICD-10-PCM code types)STEP 8: Calculate percentageDivide the count of unique MSIS-IDs from STEP 7 by the count of MSIS-IDs from STEP 6 |
| 06/02/2023 |
3.8.0 |
Data Quality Measures |
UPDATE |
Version text |
3.7.0 |
3.8.0 |
| 09/21/2023 |
3.13.0 |
MCR.003.037 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
PRV.006.087 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
PRV.006.085 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
MCR.003.035 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
PRV.005.075 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
PRV.005.073 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
PRV.004.063 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
PRV.004.061 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 07/13/2023 |
3.10.0 |
TPL.005.066 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 09/21/2023 |
3.13.0 |
TPL.005.064 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
TPL.004.055 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
TPL.004.053 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
PRV.003.042 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
PRV.003.040 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
MCR.007.085 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
MCR.007.083 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
PRV.010.128 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
PRV.010.126 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
MCR.006.076 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
MCR.006.074 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
PRV.009.118 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
PRV.009.116 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
PRV.008.109 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
PRV.008.107 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
MCR.004.057 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
MCR.004.055 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
PRV.007.097 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
PRV.007.095 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 08/10/2023 |
3.11.0 |
CRX - CLAIM PHARMACY |
UPDATE |
Title |
CRX - CLAIM PRESCRIPTION |
CRX - CLAIM PHARMACY |
| 04/21/2023 |
3.6.0 |
Data Quality Measures |
UPDATE |
Version text |
3.6.0 |
3.7.0 |
| 04/21/2023 |
3.6.0 |
EXP-39-001_1-2 |
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 Encounter: 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 = "C"2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "0" or is missingSTEP 3: Payment at the line levelOf the claims from STEP 3, select records where:1. PAYMENT-LEVEL-IND = "2"STEP 4: Medicaid paid $0 or missingOf the claims from STEP 3, select records where:1. MEDICAID-PAID-AMT = "0" or is missingSTEP 5: Calculate the percentage for the measureDivide the count of claim lines from STEP 4 by the count of claims 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 Encounter: 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 = "C"2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "0" or is missingSTEP 3: Exclude sub-capitation encountersOf 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: Payment at the line levelOf the claims from STEP 3, select records where:1. PAYMENT-LEVEL-IND = "2"STEP 5: Medicaid paid $0 or missingOf the claims from STEP 4, select records where:1. MEDICAID-PAID-AMT = "0" or is missingSTEP 6: Calculate the percentage for the measureDivide the count of claim lines from STEP 5 by the count of claims lines from STEP 4. |
| 03/10/2023 |
3.4.0 |
EXP-39-001_1-2 |
ADD |
N/A |
|
Created |
| 04/21/2023 |
3.6.0 |
EXP-37-001_1-2 |
UPDATE |
Specification |
STEP 1: Active non-duplicate OT claims during DQ 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 Encounter: 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 = "3"2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "0" or is missingSTEP 3: Payment at the line levelOf the claims from STEP 3, select records where:1. PAYMENT-LEVEL-IND = "2"STEP 4: Medicaid paid $0 or missingOf the claims from STEP 3, select records where:1. MEDICAID-PAID-AMT = "0" or is missingSTEP 5: Calculate the percentage for the measureDivide the count of claim lines from STEP 4 by the count of claims lines from STEP 3 |
STEP 1: Active non-duplicate OT claims during DQ 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 Encounter: 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 = "3"2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "0" or is missingSTEP 3: Exclude sub-capitation encountersOf 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: Payment at the line levelOf the claims from STEP 3, select records where:1. PAYMENT-LEVEL-IND = "2"STEP 5: Medicaid paid $0 or missingOf the claims from STEP 4, select records where:1. MEDICAID-PAID-AMT = "0" or is missingSTEP 6: Calculate the percentage for the measureDivide the count of claim lines from STEP 5 by the count of claims lines from STEP 4. |
| 03/10/2023 |
3.4.0 |
EXP-37-001_1-2 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
EXP-11-161_1-164 |
UPDATE |
Priority |
N/A |
High |
| 09/06/2023 |
3.12.0 |
EXP-11-161_1-164 |
UPDATE |
For ta comprehensive |
No |
TA- Inferential |
| 09/06/2023 |
3.12.0 |
EXP-11-161_1-164 |
UPDATE |
For ta inferential |
No |
Yes |
| 09/06/2023 |
3.12.0 |
EXP-11-161_1-164 |
UPDATE |
Ta min |
|
0 |
| 09/06/2023 |
3.12.0 |
EXP-11-161_1-164 |
UPDATE |
Ta max |
|
0.3 |
| 09/06/2023 |
3.12.0 |
EXP-11-161_1-164 |
UPDATE |
Threshold minimum |
TBD |
0 |
| 09/06/2023 |
3.12.0 |
EXP-11-161_1-164 |
UPDATE |
Threshold maximum |
TBD |
0.3 |
| 03/10/2023 |
3.4.0 |
EXP-11-161_1-164 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
EXP-11-160_1-163 |
UPDATE |
Priority |
N/A |
High |
| 09/06/2023 |
3.12.0 |
EXP-11-160_1-163 |
UPDATE |
For ta comprehensive |
No |
TA- Inferential |
| 09/06/2023 |
3.12.0 |
EXP-11-160_1-163 |
UPDATE |
For ta inferential |
No |
Yes |
| 09/06/2023 |
3.12.0 |
EXP-11-160_1-163 |
UPDATE |
Ta min |
|
0 |
| 09/06/2023 |
3.12.0 |
EXP-11-160_1-163 |
UPDATE |
Ta max |
|
0.15 |
| 09/06/2023 |
3.12.0 |
EXP-11-160_1-163 |
UPDATE |
Threshold minimum |
TBD |
0 |
| 09/06/2023 |
3.12.0 |
EXP-11-160_1-163 |
UPDATE |
Threshold maximum |
TBD |
0.15 |
| 03/10/2023 |
3.4.0 |
EXP-11-160_1-163 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
MIS-1-013-13 |
UPDATE |
Priority |
N/A |
High |
| 09/06/2023 |
3.12.0 |
MIS-1-013-13 |
UPDATE |
Category |
N/A |
Beneficiary demographics |
| 09/06/2023 |
3.12.0 |
MIS-1-013-13 |
UPDATE |
For ta comprehensive |
No |
TA- Inferential |
| 09/06/2023 |
3.12.0 |
MIS-1-013-13 |
UPDATE |
For ta inferential |
No |
Yes |
| 09/06/2023 |
3.12.0 |
MIS-1-013-13 |
UPDATE |
Ta min |
|
0 |
| 09/06/2023 |
3.12.0 |
MIS-1-013-13 |
UPDATE |
Ta max |
|
0.5 |
| 09/06/2023 |
3.12.0 |
MIS-1-013-13 |
UPDATE |
Threshold minimum |
TBD |
0 |
| 09/06/2023 |
3.12.0 |
MIS-1-013-13 |
UPDATE |
Threshold maximum |
TBD |
0.5 |
| 03/10/2023 |
3.4.0 |
MIS-1-013-13 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
EL-6-037-37 |
UPDATE |
Priority |
N/A |
Medium |
| 09/06/2023 |
3.12.0 |
EL-6-037-37 |
UPDATE |
Category |
N/A |
Beneficiary demographics |
| 09/06/2023 |
3.12.0 |
EL-6-037-37 |
UPDATE |
For ta comprehensive |
No |
TA- Inferential |
| 09/06/2023 |
3.12.0 |
EL-6-037-37 |
UPDATE |
For ta inferential |
No |
Yes |
| 09/06/2023 |
3.12.0 |
EL-6-037-37 |
UPDATE |
Ta min |
|
0 |
| 09/06/2023 |
3.12.0 |
EL-6-037-37 |
UPDATE |
Ta max |
|
0.1 |
| 09/06/2023 |
3.12.0 |
EL-6-037-37 |
UPDATE |
Threshold minimum |
TBD |
0 |
| 09/06/2023 |
3.12.0 |
EL-6-037-37 |
UPDATE |
Threshold maximum |
TBD |
0.1 |
| 03/10/2023 |
3.4.0 |
EL-6-037-37 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
EL-1-040-47 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 09/06/2023 |
3.12.0 |
EL-1-040-47 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 03/10/2023 |
3.4.0 |
EL-1-040-47 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
EL-1-039-46 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 09/06/2023 |
3.12.0 |
EL-1-039-46 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 03/10/2023 |
3.4.0 |
EL-1-039-46 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
EL-1-038-45 |
UPDATE |
Priority |
N/A |
High |
| 09/06/2023 |
3.12.0 |
EL-1-038-45 |
UPDATE |
Category |
N/A |
Beneficiary demographics |
| 09/06/2023 |
3.12.0 |
EL-1-038-45 |
UPDATE |
For ta comprehensive |
No |
TA- Inferential |
| 09/06/2023 |
3.12.0 |
EL-1-038-45 |
UPDATE |
For ta inferential |
No |
Yes |
| 09/06/2023 |
3.12.0 |
EL-1-038-45 |
UPDATE |
Ta min |
|
0 |
| 09/06/2023 |
3.12.0 |
EL-1-038-45 |
UPDATE |
Ta max |
|
0.99 |
| 09/06/2023 |
3.12.0 |
EL-1-038-45 |
UPDATE |
Threshold minimum |
TBD |
0 |
| 09/06/2023 |
3.12.0 |
EL-1-038-45 |
UPDATE |
Threshold maximum |
TBD |
0.99 |
| 03/10/2023 |
3.4.0 |
EL-1-038-45 |
ADD |
N/A |
|
Created |
| 04/21/2023 |
3.6.0 |
EL-6-036-36 |
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: 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: Dual eligiblesOf the MSIS IDs which meet the criteria from STEP 2, restrict to dual eligibles:1. DUAL-ELIGIBLE-CODE equals ("01" or "02" or "03" or "04" or "05" or "06" or "08" or "09" or "10")STEP 4: Variable demographics on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 34, 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: Medicare Beneficiary Identifier is missingOf the MSIS IDs that meet the criteria from STEP 4, further refine the population by keeping MSIS IDs where:1. MEDICARE-BENEFICIARY-IDENTIFIER is missingSTEP 6: Calculate percentageDivide the count of unique MSIS IDs from STEP 5 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: 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: Dual eligiblesOf the MSIS IDs which meet the criteria from STEP 2, restrict to dual eligibles:1. DUAL-ELIGIBLE-CODE equals ("01" or "02" or "03" or "04" or "05" or "06" or "08" or "09" or "10")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: Medicare Beneficiary Identifier is missingOf the MSIS IDs that meet the criteria from STEP 4, further refine the population by keeping MSIS IDs where:1. MEDICARE-BENEFICIARY-IDENTIFIER is missingSTEP 6: Calculate percentageDivide the count of unique MSIS IDs from STEP 5 by the count of unique MSIS IDs from STEP 3 |
| 04/21/2023 |
3.6.0 |
MIS-28-003-3 |
UPDATE |
Priority |
Medium |
N/A |
| 04/21/2023 |
3.6.0 |
MIS-26-005-5 |
UPDATE |
Priority |
Medium |
N/A |
| 04/21/2023 |
3.6.0 |
MIS-24-012-12 |
UPDATE |
Priority |
Medium |
N/A |
| 04/21/2023 |
3.6.0 |
MIS-22-012-12 |
UPDATE |
Priority |
Medium |
N/A |
| 04/21/2023 |
3.6.0 |
EL-3-025-30 |
UPDATE |
Annotation |
N/A |
Count the number of mandatory eligibility groups for SSI or ABD individuals with at least one MSIS ID with a primary eligibility group indicator associated with it |
| 04/21/2023 |
3.6.0 |
EL-3-025-30 |
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 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: Frequency of mandatory eligibility groupsOf the MSIS IDs that meet the criteria from STEP 2, count the number of unique MSIS IDs where ELIGIBILITY-GROUP is equal to each of the following values: 11, 12STEP 4: Count of categoriesOf the 2 mandatory eligibility group categories referenced in STEP 3, count the number of categories with at least one MSIS ID |
| 09/21/2023 |
3.13.0 |
ELG.003.031 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
ELG.012.169 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 07/13/2023 |
3.10.0 |
ELG.011.162 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 09/21/2023 |
3.13.0 |
ELG.011.160 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 07/13/2023 |
3.10.0 |
ELG.010.149 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 09/21/2023 |
3.13.0 |
ELG.010.147 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 07/14/2023 |
3.10.0 |
ELG.009.139 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 09/21/2023 |
3.13.0 |
CLT.003.213 |
UPDATE |
Coding requirement |
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) |
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 |
| 09/21/2023 |
3.13.0 |
ELG.009.137 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 07/13/2023 |
3.10.0 |
ELG.008.129 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 09/21/2023 |
3.13.0 |
ELG.008.127 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 07/13/2023 |
3.10.0 |
ELG.007.117 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 09/21/2023 |
3.13.0 |
ELG.007.115 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 07/13/2023 |
3.10.0 |
ELG.021.251 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 09/21/2023 |
3.13.0 |
ELG.021.249 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 07/13/2023 |
3.10.0 |
ELG.006.106 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 09/21/2023 |
3.13.0 |
ELG.006.104 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 07/13/2023 |
3.10.0 |
ELG.020.241 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 09/21/2023 |
3.13.0 |
ELG.020.239 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 07/13/2023 |
3.10.0 |
TPL.002.019 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 09/21/2023 |
3.13.0 |
TPL.002.017 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 07/13/2023 |
3.10.0 |
ELG.018.232 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 09/21/2023 |
3.13.0 |
ELG.018.230 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 07/13/2023 |
3.10.0 |
ELG.017.223 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 07/13/2023 |
3.10.0 |
ELG.005.082 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 09/21/2023 |
3.13.0 |
ELG.017.221 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
ELG.005.080 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
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 ID |
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) |
| 07/13/2023 |
3.10.0 |
ELG.016.212 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 07/13/2023 |
3.10.0 |
ELG.012.171 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 09/21/2023 |
3.13.0 |
COT.003.190 |
UPDATE |
Coding requirement |
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 (COT.002.037) not in ('3','C','W') then value must match Provider Identifier (PRV.005.081) |
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 |
| 09/21/2023 |
3.13.0 |
ELG.016.210 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 08/28/2023 |
3.12.0 |
CRX.002.102 |
UPDATE |
Coding requirement |
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. When Type of Claim not in ('3','C','W') then value must match Provider Identifier (PRV.005.081)4. Mandatory |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to '2'3. When Type of Claim not in ('3','C','W') then value must match Provider Identifier (PRV.005.081)4. Mandatory5. Value must exist in the NPPES NPI data file6. Nppes Entity Type Code associate with this NPI must equal ‘1’ (Individual) |
| 07/13/2023 |
3.10.0 |
ELG.004.064 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 07/13/2023 |
3.10.0 |
ELG.015.203 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 09/21/2023 |
3.13.0 |
ELG.015.201 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 08/15/2023 |
3.12.0 |
COT.003.168 |
UPDATE |
Coding requirement |
1. Value must be in Revenue Code List (VVL)2. A Revenue Code (CE) value requires an associated Revenue Charge (CE)3. Value must be 4 characters or less4. Conditional |
1. Value must be in Revenue Code List (VVL)2. A Revenue Code value requires an associated Revenue Charge3. Value must be 4 characters or less4. Conditional |
| 07/13/2023 |
3.10.0 |
ELG.014.191 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 03/24/2023 |
3.5.0 |
COT.003.169 |
UPDATE |
Medicaid valid value info |
HCPCS Code ListDental Codes ListProcedure Codes |
HCPCS Code ListDental Code ListCPT Code List |
| 09/21/2023 |
3.13.0 |
ELG.014.189 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
CIP.003.261 |
UPDATE |
Coding requirement |
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. Conditional |
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 |
| 07/13/2023 |
3.10.0 |
ELG.013.181 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 09/21/2023 |
3.13.0 |
ELG.013.179 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 07/13/2023 |
3.10.0 |
ELG.003.033 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN3. Value must be 20 characters or less |
| 02/23/2023 |
3.4.0 |
CIP.002.099 |
UPDATE |
Definition |
The date Medicaid paid this claim or adjustment. |
The date Medicaid paid this claim or adjustment. For Encounter Records (Type of Claim = 3, C, W), the date the managed care organization paid the provider for the claim or adjustment. |
| 03/10/2023 |
3.4.0 |
Data Quality Measures |
UPDATE |
Version text |
3.5.0 |
3.6.0 |
| 08/28/2023 |
3.12.0 |
CRX.003.172 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] |
1. Value must be 1 character2. Value must be in [0, 1]3. Mandatory |
| 08/28/2023 |
3.12.0 |
COT.003.234 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] |
1. Value must be 1 character2. Value must be in [0, 1]3. Mandatory |
| 08/28/2023 |
3.12.0 |
CLT.003.243 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] |
1. Value must be 1 character2. Value must be in [0, 1]3. Mandatory |
| 08/28/2023 |
3.12.0 |
CIP.003.296 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] |
1. Value must be 1 character2. Value must be in [0, 1]3. Mandatory |
| 02/16/2023 |
3.3.0 |
CRX.003.172 |
UPDATE |
Definition |
This data element indicates services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. |
To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. |
| 02/16/2023 |
3.3.0 |
COT.003.234 |
UPDATE |
Definition |
This data element indicates services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. |
To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. |
| 02/16/2023 |
3.3.0 |
CLT.003.243 |
UPDATE |
Definition |
This data element indicates services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. |
To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. |
| 02/16/2023 |
3.3.0 |
CIP.003.296 |
UPDATE |
Definition |
This data element indicates services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. |
To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. |
| 02/17/2023 |
3.3.0 |
Data Quality Measures |
UPDATE |
Version text |
3.4.0 |
3.5.0 |
| 01/27/2023 |
3.2.0 |
RULE-7239 |
ADD |
N/A |
|
Created |
| 01/27/2023 |
3.2.0 |
RULE-7220 |
ADD |
N/A |
|
Created |
| 01/27/2023 |
3.2.0 |
RULE-7569 |
ADD |
N/A |
|
Created |
| 01/27/2023 |
3.2.0 |
RULE-7446 |
ADD |
N/A |
|
Created |
| 01/27/2023 |
3.2.0 |
RULE-7445 |
ADD |
N/A |
|
Created |
| 01/27/2023 |
3.2.0 |
RULE-7444 |
ADD |
N/A |
|
Created |
| 01/27/2023 |
3.2.0 |
RULE-7443 |
ADD |
N/A |
|
Created |
| 01/27/2023 |
3.2.0 |
RULE-7442 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
RULE-7441 |
UPDATE |
Measure name |
% claim headers with a BILLING-PROV-NUM that does not have a match in PRV00007 with active provider enrollment status (PROV-MEDICAID-ENROLLMENT-STATUS-CODE in (1, 2, 3, 4, 5, 6) on Beginning Date of Service |
% of claim headers with a BILLING-PROV-NUM that does not have a match in PRV00007 with active provider enrollment status (PROV-MEDICAID-ENROLLMENT-STATUS-CODE in (1, 2, 3, 4, 5, 6) on Beginning Date of Service |
| 01/27/2023 |
3.2.0 |
RULE-7441 |
ADD |
N/A |
|
Created |
| 01/27/2023 |
3.2.0 |
RULE-7440 |
ADD |
N/A |
|
Created |
| 03/10/2023 |
3.4.0 |
RULE-7439 |
UPDATE |
Measure name |
% claim headers with a BILLING-PROV-NUM that does not have a match in PRV00007 with active provider enrollment status (PROV-MEDICAID-ENROLLMENT-STATUS-CODE in (1, 2, 3, 4, 5, 6) on Admission Date |
% of claim headers with a BILLING-PROV-NUM that does not have a match in PRV00007 with active provider enrollment status (PROV-MEDICAID-ENROLLMENT-STATUS-CODE in (1, 2, 3, 4, 5, 6) on Admission Date |
| 01/27/2023 |
3.2.0 |
RULE-7439 |
ADD |
N/A |
|
Created |
| 03/10/2023 |
3.4.0 |
RULE-7460 |
UPDATE |
Measure name |
% of claim lines with HCBS-SERVICE-CODE = 4 that are missing Waiver ID |
% of claim headers with HCBS-SERVICE-CODE = 4 that are missing Waiver ID |
| 01/27/2023 |
3.2.0 |
RULE-7460 |
ADD |
N/A |
|
Created |
| 01/27/2023 |
3.2.0 |
RULE-7459 |
ADD |
N/A |
|
Created |
| 01/27/2023 |
3.2.0 |
RULE-7458 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
EL-1-037-44 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 09/06/2023 |
3.12.0 |
EL-1-037-44 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 09/06/2023 |
3.12.0 |
EL-1-037-44 |
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 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 OtherOf the MSIS IDs that meet the criteria from STEP 2, further restrict the population by keeping MSIS IDs where:1. RACE equals “018”on any record segment Step 4 : MSIS IDs where ethnicity is missing, unspecified, or invalidOf the MSIS IDs that meet the criteria from STEP 3, further refine the population by keeping MSIS IDs where:1a. ETHNICITY-CODE is not “0,” “1,” “2,” “3,” “4,” or “5”OR1b. ETHNICITY-CODE is missingSTEP 5: Calculate percentage Divide 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: 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 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 OtherOf the MSIS IDs that meet the criteria from STEP 2, further restrict the population by keeping MSIS IDs where:1. RACE equals “018”on any record segmentSTEP 4: Ethnicity information on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 3, join to segment ETHNICITY-INFORMATION-ELG00015 by keeping active records that satisfy the following criteria:1a. ETHNICITY-DECLARATION-EFF-DATE <= last day of the DQ report month2a. ETHNICITY-DECLARATION-END-DATE >= last day of the DQ report month OR missingOR1b. ETHNICITY-DECLARATION-EFF-DATE is missing2b. ETHNICITY-DECLARATION-END-DATE is missingSTEP 5 : MSIS IDs where ethnicity is missing, unspecified, or invalidOf the MSIS IDs that meet the criteria from STEP 4, further refine the population by keeping MSIS IDs where:1a. ETHNICITY-CODE is not “0,” “1,” “2,” “3,” “4,” or “5”OR1b. ETHNICITY-CODE is missingSTEP 6: Calculate percentage Divide the count of unique MSIS IDs from STEP 5 by the count of unique MSIS IDs from STEP 3 |
| 01/27/2023 |
3.2.0 |
EL-1-037-44 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
EL-1-036-43 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 09/06/2023 |
3.12.0 |
EL-1-036-43 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 09/06/2023 |
3.12.0 |
EL-1-036-43 |
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 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 the population by keeping MSIS IDs where:1. RACE = “012,” "013," "014," "015," or "016" on any record segment Step 4 : MSIS IDs where ethnicity is missing, unspecified, or invalidOf the MSIS IDs that meet the criteria from STEP 3, further refine the population by keeping MSIS IDs where:1a. ETHNICITY-CODE is not “0,” “1,” “2,” “3,” “4,” or “5”OR1b. ETHNICITY-CODE is missingSTEP 5: Calculate percentage Divide 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: 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 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 the population by keeping MSIS IDs where:1. RACE = “012,” "013," "014," "015," or "016" on any record segmentSTEP 4: Ethnicity information on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 3, join to segment ETHNICITY-INFORMATION-ELG00015 by keeping active records that satisfy the following criteria:1a. ETHNICITY-DECLARATION-EFF-DATE <= last day of the DQ report month2a. ETHNICITY-DECLARATION-END-DATE >= last day of the DQ report month OR missingOR1b. ETHNICITY-DECLARATION-EFF-DATE is missing2b. ETHNICITY-DECLARATION-END-DATE is missingSTEP 5 : MSIS IDs where ethnicity is missing, unspecified, or invalidOf the MSIS IDs that meet the criteria from STEP 4, further refine the population by keeping MSIS IDs where:1a. ETHNICITY-CODE is not “0,” “1,” “2,” “3,” “4,” or “5”OR1b. ETHNICITY-CODE is missingSTEP 6: Calculate percentage Divide the count of unique MSIS IDs from STEP 5 by the count of unique MSIS IDs from STEP 3 |
| 01/27/2023 |
3.2.0 |
EL-1-036-43 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
EL-1-035-42 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 09/06/2023 |
3.12.0 |
EL-1-035-42 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 09/06/2023 |
3.12.0 |
EL-1-035-42 |
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 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 the population by keeping MSIS IDs where:1. RACE = “004,” "005," "006," "007," "008," "009," "010," or "011" on any record segment Step 4 : MSIS IDs where ethnicity is missing, unspecified, or invalidOf the MSIS IDs that meet the criteria from STEP 3, further refine the population by keeping MSIS IDs where:1a. ETHNICITY-CODE is not “0,” “1,” “2,” “3,” “4,” or “5”OR1b. ETHNICITY-CODE is missingSTEP 4: Calculate percentage Divide 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: 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 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 the population by keeping MSIS IDs where:1. RACE = “004,” "005," "006," "007," "008," "009," "010," or "011" on any record segmentSTEP 4: Ethnicity information on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 3, join to segment ETHNICITY-INFORMATION-ELG00015 by keeping active records that satisfy the following criteria:1a. ETHNICITY-DECLARATION-EFF-DATE <= last day of the DQ report month2a. ETHNICITY-DECLARATION-END-DATE >= last day of the DQ report month OR missingOR1b. ETHNICITY-DECLARATION-EFF-DATE is missing2b. ETHNICITY-DECLARATION-END-DATE is missingSTEP 5 : MSIS IDs where ethnicity is missing, unspecified, or invalidOf the MSIS IDs that meet the criteria from STEP 4, further refine the population by keeping MSIS IDs where:1a. ETHNICITY-CODE is not “0,” “1,” “2,” “3,” “4,” or “5”OR1b. ETHNICITY-CODE is missingSTEP 6: Calculate percentage Divide the count of unique MSIS IDs from STEP 5 by the count of unique MSIS IDs from STEP 3 |
| 01/27/2023 |
3.2.0 |
EL-1-035-42 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
EL-1-034-41 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 09/06/2023 |
3.12.0 |
EL-1-034-41 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 09/06/2023 |
3.12.0 |
EL-1-034-41 |
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 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 the population by keeping MSIS IDs where:1. RACE equals “003”on any record segment Step 4 : MSIS IDs where ethnicity is missing, unspecified, or invalidOf the MSIS IDs that meet the criteria from STEP 3, further refine the population by keeping MSIS IDs where:1a. ETHNICITY-CODE is not “0,” “1,” “2,” “3,” “4,” or “5”OR1b. ETHNICITY-CODE is missingSTEP 5: Calculate percentage Divide 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: 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 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 the population by keeping MSIS IDs where:1. RACE equals “003”on any record segmentSTEP 4: Ethnicity information on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 3, join to segment ETHNICITY-INFORMATION-ELG00015 by keeping active records that satisfy the following criteria:1a. ETHNICITY-DECLARATION-EFF-DATE <= last day of the DQ report month2a. ETHNICITY-DECLARATION-END-DATE >= last day of the DQ report month OR missingOR1b. ETHNICITY-DECLARATION-EFF-DATE is missing2b. ETHNICITY-DECLARATION-END-DATE is missingSTEP 5 : MSIS IDs where ethnicity is missing, unspecified, or invalidOf the MSIS IDs that meet the criteria from STEP 4, further refine the population by keeping MSIS IDs where:1a. ETHNICITY-CODE is not “0,” “1,” “2,” “3,” “4,” or “5”OR1b. ETHNICITY-CODE is missingSTEP 6: Calculate percentage Divide the count of unique MSIS IDs from STEP 5 by the count of unique MSIS IDs from STEP 3 |
| 01/27/2023 |
3.2.0 |
EL-1-034-41 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
EL-1-033-40 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 09/06/2023 |
3.12.0 |
EL-1-033-40 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 09/06/2023 |
3.12.0 |
EL-1-033-40 |
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 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 Black or African AmericanOf the MSIS IDs that meet the criteria from STEP 2, further restrict the population by keeping MSIS IDs where:1. RACE equals “002”on any record segment Step 4 : MSIS IDs where ethnicity is missing, unspecified, or invalidOf the MSIS IDs that meet the criteria from STEP 3, further refine the population by keeping MSIS IDs where:1a. ETHNICITY-CODE is not “0,” “1,” “2,” “3,” “4,” or “5”OR1b. ETHNICITY-CODE is missingSTEP 5: Calculate percentage Divide 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: 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 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 Black or African AmericanOf the MSIS IDs that meet the criteria from STEP 2, further restrict the population by keeping MSIS IDs where:1. RACE equals “002”on any record segmentSTEP 4: Ethnicity information on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 3, join to segment ETHNICITY-INFORMATION-ELG00015 by keeping active records that satisfy the following criteria:1a. ETHNICITY-DECLARATION-EFF-DATE <= last day of the DQ report month2a. ETHNICITY-DECLARATION-END-DATE >= last day of the DQ report month OR missingOR1b. ETHNICITY-DECLARATION-EFF-DATE is missing2b. ETHNICITY-DECLARATION-END-DATE is missingSTEP 5 : MSIS IDs where ethnicity is missing, unspecified, or invalidOf the MSIS IDs that meet the criteria from STEP 4, further refine the population by keeping MSIS IDs where:1a. ETHNICITY-CODE is not “0,” “1,” “2,” “3,” “4,” or “5”OR1b. ETHNICITY-CODE is missingSTEP 6: Calculate percentage Divide the count of unique MSIS IDs from STEP 5 by the count of unique MSIS IDs from STEP 3 |
| 01/27/2023 |
3.2.0 |
EL-1-033-40 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
EL-1-032-39 |
UPDATE |
Threshold minimum |
TBD |
N/A |
| 09/06/2023 |
3.12.0 |
EL-1-032-39 |
UPDATE |
Threshold maximum |
TBD |
N/A |
| 09/06/2023 |
3.12.0 |
EL-1-032-39 |
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 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 WhiteOf the MSIS IDs that meet the criteria from STEP 2, further restrict the population by keeping MSIS IDs where:1. RACE equals “001”on any record segment Step 4 : MSIS IDs where ethnicity is missing, unspecified, or invalidOf the MSIS IDs that meet the criteria from STEP 3, further refine the population by keeping MSIS IDs where:1a. ETHNICITY-CODE is not “0,” “1,” “2,” “3,” “4,” or “5”OR1b. ETHNICITY-CODE is missingSTEP 5: Calculate percentage Divide 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: 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 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 WhiteOf the MSIS IDs that meet the criteria from STEP 2, further restrict the population by keeping MSIS IDs where:1. RACE equals “001”on any record segmentSTEP 4: Ethnicity information on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 3, join to segment ETHNICITY-INFORMATION-ELG00015 by keeping active records that satisfy the following criteria:1a. ETHNICITY-DECLARATION-EFF-DATE <= last day of the DQ report month2a. ETHNICITY-DECLARATION-END-DATE >= last day of the DQ report month OR missingOR1b. ETHNICITY-DECLARATION-EFF-DATE is missing2b. ETHNICITY-DECLARATION-END-DATE is missingSTEP 5 : MSIS IDs where ethnicity is missing, unspecified, or invalidOf the MSIS IDs that meet the criteria from STEP 4, further refine the population by keeping MSIS IDs where:1a. ETHNICITY-CODE is not “0,” “1,” “2,” “3,” “4,” or “5”OR1b. ETHNICITY-CODE is missingSTEP 6: Calculate percentage Divide the count of unique MSIS IDs from STEP 5 by the count of unique MSIS IDs from STEP 3 |
| 01/27/2023 |
3.2.0 |
EL-1-032-39 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
PRV-2-011-11 |
UPDATE |
Measure name |
% of non-atypical providers that do not have an NPI |
% of providers that require NPI (non-atypical) that are missing NPI (PROV-IDENTIFIER-TYPE=2) |
| 09/06/2023 |
3.12.0 |
PRV-2-011-11 |
UPDATE |
Priority |
N/A |
Medium |
| 09/06/2023 |
3.12.0 |
PRV-2-011-11 |
UPDATE |
Category |
N/A |
Provider classification |
| 09/06/2023 |
3.12.0 |
PRV-2-011-11 |
UPDATE |
For ta comprehensive |
No |
TA- Inferential |
| 09/06/2023 |
3.12.0 |
PRV-2-011-11 |
UPDATE |
For ta inferential |
No |
Yes |
| 09/06/2023 |
3.12.0 |
PRV-2-011-11 |
UPDATE |
Ta min |
|
0 |
| 09/06/2023 |
3.12.0 |
PRV-2-011-11 |
UPDATE |
Ta max |
|
0.1 |
| 09/06/2023 |
3.12.0 |
PRV-2-011-11 |
UPDATE |
Threshold minimum |
TBD |
0 |
| 09/06/2023 |
3.12.0 |
PRV-2-011-11 |
UPDATE |
Threshold maximum |
TBD |
0.1 |
| 09/06/2023 |
3.12.0 |
PRV-2-011-11 |
UPDATE |
Annotation |
Calculate the percent of providers that are not atypical and missing NPI |
Calculate the percent of providers that require NPI (are not atypical) and are missing NPI |
| 01/27/2023 |
3.2.0 |
PRV-2-011-11 |
ADD |
N/A |
|
Created |
| 03/10/2023 |
3.4.0 |
EL-6-032-35 |
UPDATE |
Priority |
High |
Medium |
| 06/02/2023 |
3.8.0 |
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 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 |
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 |
| 06/02/2023 |
3.8.0 |
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 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 |
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 |
| 06/02/2023 |
3.8.0 |
PRV-6-002-2 |
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 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 Lookup Designation is "Facility or Group" or 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:1a. PROV-IDENTIFIER-TYPE and PROVIDER-CLASSIFICATION-CODE match values in Provider Classification lookup tableAND1b. Provider Classification Lookup Designation = “Facility” or "Group"OR2. PROV-IDENTIFIER-TYPE and PROVIDER-CLASSIFICATION-CODE do not equal to values in Provider Classification lookup tableOR3. PROV-IDENTIFIER-TYPE is missingOR4. PROVIDER-CLASSIFICATION-CODE is 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 |
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 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 Lookup Designation is "Facility or Group" or 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:1a. PROV-IDENTIFIER-TYPE and PROVIDER-CLASSIFICATION-CODE match values in Provider Classification lookup tableAND1b. Provider Classification Lookup Designation is never “Individual"OR2. PROV-IDENTIFIER-TYPE and PROVIDER-CLASSIFICATION-CODE are never equal to values in Provider Classification lookup tableOR3. PROV-IDENTIFIER-TYPE is always missingOR4. 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 |
| 06/02/2023 |
3.8.0 |
PRV-6-001-1 |
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 Lookup Designation is "Individual" or 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:1a. PROV-IDENTIFIER-TYPE and PROVIDER-CLASSIFICATION-CODE match values in Provider Classification lookup tableAND1b. Provider Classification Lookup Designation = “Individual”OR2. PROV-IDENTIFIER-TYPE and PROVIDER-CLASSIFICATION-CODE do not equal to values in Provider Classification lookup tableOR3. PROV-IDENTIFIER-TYPE is missingOR4. PROVIDER-CLASSIFICATION-CODE is 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 |
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 Lookup Designation is "Individual" or 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:1a. PROV-IDENTIFIER-TYPE and PROVIDER-CLASSIFICATION-CODE match values in Provider Classification lookup tableAND1b. Provider Classification Lookup Designation is never “Non-Individual”OR2. PROV-IDENTIFIER-TYPE and PROVIDER-CLASSIFICATION-CODE are never equal to values in Provider Classification lookup tableOR3. PROV-IDENTIFIER-TYPE is always missingOR4. 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 |
| 04/21/2023 |
3.6.0 |
PRV-2-010-10 |
UPDATE |
Annotation |
Calculate the percent of submitting-state-provider-IDs that are individual providers but have more than one reported NPI |
Calculate the percent of submitting state provider IDs that are individual providers but have more than one reported NPI |
| 02/14/2023 |
3.3.0 |
Data Quality Measures |
UPDATE |
Threshold and measures combined |
None |
225 |
| 09/21/2023 |
3.13.0 |
ELG.010.155 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 08/14/2023 |
3.12.0 |
CIP.002.096 |
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. Value must be less than or equal to associated Adjudication Date (CE) value.4. Value must be greater than or equal to associated Admission Date (CE) value.5. Value must be greater than or equal to associated eligible Date of Birth (CE) value.6. Value must be less than or equal to associated eligible Date of Death (CE) value.7. Conditional8. If associated Adjustment Indicator (CIP.002.026) does not equal "1" (Non-denied claims) and Patient Status (CIP.002.199) is not equal to "30" value must be populated.9. When populated, Discharge Hour (CIP.002.097) must be populated |
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. Value must be less than or equal to associated Adjudication Date value.4. Value must be greater than or equal to associated Admission Date value.5. Value must be greater than or equal to associated eligible Date of Birth value.6. Value must be less than or equal to associated eligible Date of Death value.7. Conditional8. If associated Adjustment Indicator (CIP.002.026) does not equal "1" (Non-denied claims) and Patient Status (CIP.002.199) is not equal to "30" value must be populated.9. When populated, Discharge Hour (CIP.002.097) must be populated |
| 08/09/2023 |
3.11.0 |
CRX.002.041 |
UPDATE |
Definition |
The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim. |
The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider. |
| 08/14/2023 |
3.12.0 |
ELG.001.010 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be equal to or after associated Start of Time Period (CE)6. Mandatory |
1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be equal to or after associated Start of Time Period6. Mandatory |
| 08/09/2023 |
3.11.0 |
CRX.002.039 |
UPDATE |
Definition |
The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial
transactions. |
The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 08/09/2023 |
3.11.0 |
CLT.002.065 |
UPDATE |
Definition |
The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim. |
The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 08/09/2023 |
3.11.0 |
CLT.002.064 |
UPDATE |
Definition |
The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. On managed care encounters the Allowed Amount is
determined by the managed care organization. |
The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. On managed care encounters the Allowed Amount is determined by the managed care organization.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity allowed for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 08/09/2023 |
3.11.0 |
CLT.002.063 |
UPDATE |
Definition |
The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial
transactions. |
The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 07/12/2023 |
3.10.0 |
ELG.005.097 |
UPDATE |
Coding requirement |
1. Value must be in Restricted Benefits Code List (VVL)2. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "05", then Eligibility Group (ELG.005.087) must be "24"3. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "06", then Eligibility Group (ELG.005.087) must be "26"4. (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "02", then Eligibility Group (ELG.005.087) must be "23"5. (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "04", then Eligibility Group (ELG.005.087) must be "25"6. (Restricted Benefits) if value is "3", then Dual Eligible Code (ELG.005.085) cannot be "00"7. Mandatory8. If value is populated, then Eligibility Group (ELG.005.087) must be populated.9. If value is "6" then Eligibility Group(ELG.DE.087) must be in ("35", "70")10. If value is "1" or "7" then Eligibility Group (EGL.DE.087) must be in ("72", "73", "74", "75") and State Plan Option Type (ELG.DE.163) must equal to "06"11. (Restricted Pregnancy-Related) if value is "4", then associated Sex (ELG.002.023) value must be "F"12. (Non-Citizen) if value is "2", then associated Citizenship Indicator (ELG.003.040) value must not be equal to "1"13. If value is "D", there must be a corresponding MFP enrollment segment (ELG00010) with Effective and End dates that are within the timespan of this segment14. Value must be 1 character15. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "01", then Eligibility Group (ELG.005.087) must be "23"16. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "03", then Eligibility Group (ELG.005.087) must be "25" |
Value must be in Restricted Benefits Code List (VVL)2. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "05", then Eligibility Group (ELG.005.087) must be "24"3. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "06", then Eligibility Group (ELG.005.087) must be "26"4. (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "02", then Eligibility Group (ELG.005.087) must be "23"5. (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "04", then Eligibility Group (ELG.005.087) must be "25"6. (Restricted Benefits) if value is "3", then Dual Eligible Code (ELG.005.085) cannot be "00"7. Mandatory8. If value is populated, then Eligibility Group (ELG.005.087) must be populated.9. If value is "6" then Eligibility Group(ELG.DE.087) must be in ("35", "70")10. If value is "1" or "7" then Eligibility Group (EGL.DE.087) must be in ("72", "73", "74", "75") and State Plan Option Type (ELG.DE.163) must equal to "06"11. (Restricted Pregnancy-Related) if value is "4", then associated Sex (ELG.002.023) value must be "F"12. (Non-Citizen) if value is "2", then associated Citizenship Indicator (ELG.003.040) value must not be equal to "1"13. If value is "D", there must be a corresponding MFP enrollment segment (ELG00010) with Effective and End dates that are within the timespan of this segment14. Value must be 1 character15. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "01", then Eligibility Group (ELG.005.087) must be "23"16. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "03", then Eligibility Group (ELG.005.087) must be "25"17. (Restricted Benefits) if value is "G", then Dual Eligible Code (ELG.005.085) must be in (‘01’, ‘03', ‘06’) |
| 08/01/2023 |
3.11.0 |
ELG.005.086 |
UPDATE |
Coding requirement |
1. Value must be in Primary Eligibility Group Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. Value must be 1 character5. Mandatory |
1. Value must be in Primary Eligibility Group Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1]4. Mandatory |
| 08/09/2023 |
3.11.0 |
COT.002.050 |
UPDATE |
Definition |
The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim. |
The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field.For sub-capitation payments, this represents the amount paid by the managed care plan to the sub-capitated entity. |
| 08/09/2023 |
3.11.0 |
COT.002.049 |
UPDATE |
Definition |
The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. On managed care encounters the Allowed Amount is
determined by the managed care organization. |
The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. On managed care encounters the Allowed Amount is determined by the managed care organization.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity allowed for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 08/09/2023 |
3.11.0 |
COT.002.048 |
UPDATE |
Definition |
The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial
transactions. |
The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 08/09/2023 |
3.11.0 |
COT.002.034 |
UPDATE |
Definition |
For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, the date on which the service covered by this claim ended. For capitation premium payments, the date on
which the period of coverage related to this payment ends/ended. For financial transactions reported to the OT file, populate with the last day of the time period covered by this financial transaction. |
For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, the date on which the service covered by this claim ended. For capitation premium payments, the date on which the period of coverage related to this payment ends/ended. For financial transactions reported to the OT file, populate with the last day of the time period covered by this financial transaction.For sub-capitation payments, this represents the last date of the period the sub-capitation payment covers. |
| 08/09/2023 |
3.11.0 |
COT.002.033 |
UPDATE |
Definition |
For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, this would be the date on which the service
covered by this claim began. For capitation premium payments, the date on which the period of coverage related to this payment began. For financial transactions reported to the OT file, populate with the first day of the time period covered by this financial transaction. |
For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, this would be the date on which the service covered by this claim began. For capitation premium payments, the date on which the period of coverage related to this payment began. For financial transactions reported to the OT file, populate with the first day of the time period covered by this financial transaction.For sub-capitation payments, this represents the first date of the period the sub-capitation payment covers. |
| 08/09/2023 |
3.11.0 |
COT.003.167 |
UPDATE |
Definition |
For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, the date on which the service covered by this claim ended. For capitation premium payments, the date on
which the period of coverage related to this payment ends/ended. For financial transactions reported to the OT file, populate with the last day of the time period covered by this financial transaction. |
For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, the date on which the service covered by this claim ended. For capitation premium payments, the date on which the period of coverage related to this payment ends/ended. For financial transactions reported to the OT file, populate with the last day of the time period covered by this financial transaction.For sub-capitation payments, this represents the last date of the period the sub-capitation payment covers. |
| 08/09/2023 |
3.11.0 |
COT.003.166 |
UPDATE |
Definition |
For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, this would be the date on which the service
covered by this claim began. For capitation premium payments, the date on which the period of coverage related to this payment began. For financial transactions reported to the OT file, populate with the first day of the time period covered by this financial transaction. |
For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, this would be the date on which the service covered by this claim began. For capitation premium payments, the date on which the period of coverage related to this payment began. For financial transactions reported to the OT file, populate with the first day of the time period covered by this financial transaction.For sub-capitation payments, this represents the first date of the period the sub-capitation payment covers. |
| 08/09/2023 |
3.11.0 |
CIP.002.114 |
UPDATE |
Definition |
The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim. |
The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 08/09/2023 |
3.11.0 |
CIP.002.113 |
UPDATE |
Definition |
The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. On managed care encounters the Allowed Amount is
determined by the managed care organization. |
The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. On managed care encounters the Allowed Amount is determined by the managed care organization.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity allowed for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 08/09/2023 |
3.11.0 |
CIP.002.112 |
UPDATE |
Definition |
The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial
transactions. |
The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. Report a null value in this field if the provider is a sub-capitated network provider. |
| 09/21/2023 |
3.13.0 |
PRV.006.088 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/09/2023 |
3.11.0 |
ELG.005.095 |
UPDATE |
Definition |
The reason for a complete loss/termination in an individual's eligibility for Medicaid and CHIP. The end date of the segment in which the value is reported must represent the date that the complete loss/termination of Medicaid and CHIP eligibility occurred. The reason for the termination represents the reason that the segment in which it was reported was closed. If for a single termination in eligibility for a single individual, there are multiple distinct co-occurring values in the state's system explaining the reason for the termination, and if one of the multiple co-occurring values maps to T-MSIS ELIGIBILITY-CHANGE-REASON value '21' (Other) or '22' (Unknown), then the state should not report the co-occurring value '21' and/or '22' to T-MSIS. If there are multiple co-occurring distinct values between '01' and '19', then the state should choose whichever is first in the state's system. Of the values that could logically co-occur in the range of '01' through '19', CMS does not currently have a preference for any one value over another. |
The reason for a complete loss/termination in an individual's eligibility for Medicaid and CHIP. The end date of the segment in which the value is reported must represent the date that the complete loss/termination of Medicaid and CHIP eligibility occurred. The reason for the termination represents the reason that the segment in which it was reported was closed. If for a single termination in eligibility for a single individual there are multiple distinct co-occurring values in the state's system explaining the reason for the termination, and if one of the multiple co-occurring values maps to T-MSIS ELIGIBILITY-CHANGE-REASON value '21' (Other) or '22' (Unknown), then the state should not report the co-occurring value '21' and/or '22' to T-MSIS. If there are multiple co-occurring distinct values between '01' and '19', then the state should choose whichever is first in the state's system. Of the values that could logically co-occur in the range of '01' through '19', CMS does not currently have a preference for any one value over another. Do not populate if at the time someone loses Medicaid eligibility they become eligible for and enrolled in CHIP. Also do not populate if at the time someone loses CHIP eligibility they become eligible for and enrolled in Medicaid.| |
| 02/23/2023 |
3.4.0 |
CIP.002.099 |
UPDATE |
Definition |
The date Medicaid paid this claim or adjustment. For Encounter Records (Type of Claim = 3, C, W), the date the managed care organization paid the provider for the claim or adjustment. |
The date Medicaid paid this claim or adjustment. |
| 09/21/2023 |
3.13.0 |
PRV.006.089 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/21/2023 |
3.13.0 |
ELG.003.057 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
TPL.006.073 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
TPL.003.030 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
PRV.002.017 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
MCR.005.064 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
MCR.002.017 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
ELG.022.258 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
ELG.002.017 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
CRX.003.109 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
COT.003.155 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
CLT.003.185 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
CIP.003.232 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 08/15/2023 |
3.12.0 |
CLT.003.198 |
UPDATE |
Coding requirement |
1. Value must be in Revenue Code List (VVL)2. A Revenue Code (CE) value requires an associated Revenue Charge (CE)3. Value must be 4 characters or less4. Mandatory |
1. Value must be in Revenue Code List (VVL)2. A Revenue Code value requires an associated Revenue Charge3. Value must be 4 characters or less4. Mandatory |
| 08/15/2023 |
3.12.0 |
CIP.003.245 |
UPDATE |
Coding requirement |
1. Value must be in Revenue Code List (VVL)2. A Revenue Code (CE) value requires an associated Revenue Charge (CE)3. Value must be 4 characters or less4. Mandatory |
1. Value must be in Revenue Code List (VVL)2. A Revenue Code value requires an associated Revenue Charge3. Value must be 4 characters or less4. Mandatory |
| 09/21/2023 |
3.13.0 |
MCR.004.058 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/28/2023 |
3.12.0 |
TPL.006.081 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
TPL.006.081 |
UPDATE |
Coding requirement |
1. Value must be in State Code List (VVL)2. Value must be 2 characters3. Optional |
1. Value must be in State Code List (VVL)2. Value must be 2 characters3. Situational |
| 09/21/2023 |
3.13.0 |
MCR.007.086 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/28/2023 |
3.12.0 |
TPL.006.091 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
TPL.006.091 |
UPDATE |
Coding requirement |
1. Value must be 30 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 30 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 08/28/2023 |
3.12.0 |
TPL.006.090 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
TPL.006.090 |
UPDATE |
Coding requirement |
1. Value must be 10 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 10 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
TPL.006.084 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 08/28/2023 |
3.12.0 |
TPL.006.083 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
TPL.006.083 |
UPDATE |
Coding requirement |
1. Value must be 10-digit number2. Optional |
1. Value must be 10-digit number2. Situational |
| 08/28/2023 |
3.12.0 |
TPL.006.082 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
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. Optional |
1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011)2. Situational |
| 08/28/2023 |
3.12.0 |
TPL.006.080 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
TPL.006.080 |
UPDATE |
Coding requirement |
1. Value must be 28 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 28 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 08/14/2023 |
3.12.0 |
TPL.006.079 |
UPDATE |
Coding requirement |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 (CE) or Address Line 2 (CE) value(s)3. If Address Line 2 is not populated, then value should not be populated4. Value must not contain a pipe or asterisk symbols5. Conditional |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 or Address Line 2 value(s)3. If Address Line 2 is not populated, then value should not be populated4. Value must not contain a pipe or asterisk symbols5. Conditional |
| 08/14/2023 |
3.12.0 |
TPL.006.078 |
UPDATE |
Coding requirement |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 (CE) or Address Line 3 (CE) value(s)3. There must be an Address Line 1 (CE) in order to have an Address Line 2 (CE)4. Value must not contain a pipe or asterisk symbols5. Conditional |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 or Address Line 3 value(s)3. There must be an Address Line 1 in order to have an Address Line 24. Value must not contain a pipe or asterisk symbols5. Conditional |
| 08/14/2023 |
3.12.0 |
TPL.006.077 |
UPDATE |
Coding requirement |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 2 (CE) or Address Line 3 (CE) value(s)3. Value must not contain a pipe or asterisk symbols4. Optional5. When populated, the associated Address Type is required |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 2 or Address Line 3 value(s)3. Value must not contain a pipe or asterisk symbols4. Optional5. When populated, the associated Address Type is required |
| 09/21/2023 |
3.13.0 |
TPL.006.076 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 09/21/2023 |
3.13.0 |
TPL.006.075 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 08/15/2023 |
3.12.0 |
TPL.006.074 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
TPL.005.070 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
TPL.005.068 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
TPL.005.067 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/15/2023 |
3.12.0 |
TPL.005.065 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
TPL.004.061 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
TPL.004.059 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
TPL.004.058 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/21/2023 |
3.13.0 |
TPL.004.056 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/15/2023 |
3.12.0 |
TPL.004.054 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 09/21/2023 |
3.13.0 |
TPL.003.089 |
UPDATE |
Segment key field identifier |
Not Applicable |
7 |
| 08/21/2023 |
3.12.0 |
TPL.003.050 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
TPL.003.048 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
TPL.003.036 |
UPDATE |
Segment key field identifier |
Not Applicable |
6 |
| 09/21/2023 |
3.13.0 |
TPL.003.035 |
UPDATE |
Segment key field identifier |
Not Applicable |
5 |
| 09/21/2023 |
3.13.0 |
TPL.003.034 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/21/2023 |
3.13.0 |
TPL.003.033 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 07/13/2023 |
3.10.0 |
TPL.003.032 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 08/15/2023 |
3.12.0 |
TPL.003.031 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
TPL.002.027 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
TPL.002.025 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 08/28/2023 |
3.12.0 |
TPL.002.020 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in TPL Health Insurance Coverage Indicator List (VVL)4. Value must be 1 character5. Mandatory6. When value equals '1', there must be one corresponding TPL Medicaid Eligible Person Health Insurance Coverage Information (TPL.003) segment with the same MSIS ID. |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in TPL Health Insurance Coverage Indicator List (VVL)4. Mandatory5. When value equals '1', there must be one corresponding TPL Medicaid Eligible Person Health Insurance Coverage Information (TPL.003) segment with the same MSIS ID. |
| 08/14/2023 |
3.12.0 |
TPL.002.018 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
TPL.001.014 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
TPL.001.012 |
UPDATE |
Coding requirement |
1. Value must be in SSN Indicator List (VVL)2. Value must be 1 character3. Mandatory |
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) |
| 08/14/2023 |
3.12.0 |
TPL.001.010 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be equal to or after associated Start of Time Period (CE)6. Mandatory |
1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be equal to or after associated Start of Time Period6. Mandatory |
| 08/14/2023 |
3.12.0 |
TPL.001.009 |
UPDATE |
Coding requirement |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be before associated End of Time Period (CE)6. Mandatory |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be before associated End of Time Period6. Mandatory |
| 08/14/2023 |
3.12.0 |
TPL.001.008 |
UPDATE |
Coding requirement |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period (CE)6. Mandatory |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period6. Mandatory |
| 08/28/2023 |
3.12.0 |
TPL.001.002 |
UPDATE |
Coding requirement |
1. Value must be 10 characters or less2. Value must not include the pipe ("|") symbol3. Mandatory |
1. Value must be 10 characters or less2. Value must be in the Data Dictionary Version List (VVL)3. Mandatory |
| 08/21/2023 |
3.12.0 |
PRV.010.136 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
PRV.010.134 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/21/2023 |
3.13.0 |
PRV.010.130 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
PRV.010.129 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/15/2023 |
3.12.0 |
PRV.010.127 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
PRV.009.123 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
PRV.009.121 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 06/14/2023 |
3.9.0 |
PRV.009.120 |
UPDATE |
Definition |
A data element to identify the Medicaid/CHIP programs, waivers and demonstrations in which the provider participates.
If Affiliated Program Type = 2 (Health Plan State-assigned health plan ID), then the value in Affiliated Program ID is the state-assigned plan ID of the health plan in which a provider is enrolled to provide services. If Affiliated Program Type = 3 (Waiver), then the value in Affiliated Program ID is the core Federal Waiver ID in which a provider is
allowed to deliver services to eligible beneficiaries. If Affiliated Program Type = 4 (Health Home Entity), then the value in Affiliated Program ID is the name of a health home in which a provider is participating. If Affiliated Program Type = 5 (Other), then the value in Affiliated Program ID is an identifier for something other than a health plan,
waiver, or health home entity. |
A data element to identify the Medicaid/CHIP programs, waivers and demonstrations in which the provider participates. |
| 09/21/2023 |
3.13.0 |
PRV.009.119 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/15/2023 |
3.12.0 |
PRV.009.117 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
PRV.008.113 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
PRV.008.111 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
PRV.008.110 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/14/2023 |
3.12.0 |
PRV.008.108 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
PRV.007.104 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 08/14/2023 |
3.12.0 |
PRV.007.096 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
PRV.006.092 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
PRV.006.090 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 01/03/2023 |
3.2.0 |
PRV.006.089 |
UPDATE |
Medicaid valid value info |
*Valid values for PROV-CLASSIFICATION-CODE depend on the value submitted for PROV-CLASSIFICATION-TYPE. All four valid value sets are shown here below.If PROV-CLASSIFICATION-TYPE = 1 then you should submit a valid value from the PROV-CLASSIFICATION-CODE-TYPE-1 valid value set.If PROV-CLASSIFICATION-TYPE = 2 then you should submit a valid value from the PROV-SPECIALTY valid value set.If PROV-CLASSIFICATION-TYPE = 3 then you should submit a valid value from the PROV-TYPE valid value set.If PROV-CLASSIFICATION-TYPE = 4 then you should submit a valid value from the PROV-CLASSIFICATION-CODE-TYPE-4 valid value set. |
*Valid values for PROV-CLASSIFICATION-CODE depend on the value submitted for PROV-CLASSIFICATION-TYPE. All four valid value sets are shown here below.If PROV-CLASSIFICATION-TYPE = 1 then refer to the Provider Taxonomy Code ListIf PROV-CLASSIFICATION-TYPE = 2 then you should submit a valid value from the PROV-SPECIALTY valid value set.If PROV-CLASSIFICATION-TYPE = 3 then you should submit a valid value from the PROV-TYPE valid value set.If PROV-CLASSIFICATION-TYPE = 4 then you should submit a valid value from the PROV-CLASSIFICATION-CODE-TYPE-4 valid value set. |
| 01/26/2023 |
3.2.0 |
PRV.006.088 |
UPDATE |
Definition |
A code to identify the schema used in the Provider Classification Code field to categorize providers. See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Provider Classification Type and Provider Classification Code in the T-MSIS Provider File"
https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47562
A provider may be reported with multiple active record segments with the same Provider Classification Type if different Provider Classification Code values apply. |
A code to identify the schema used in the Provider Classification Code field to categorize providers. See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Provider Classification Type and Provider Classification Code in the T-MSIS Provider File" https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/98581 . A provider may be reported with multiple active record segments with the same Provider Classification Type if different Provider Classification Code values apply. |
| 08/14/2023 |
3.12.0 |
PRV.006.086 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
PRV.005.082 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
PRV.005.081 |
UPDATE |
Segment key field identifier |
Not Applicable |
6 |
| 09/21/2023 |
3.13.0 |
PRV.005.079 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
PRV.005.078 |
UPDATE |
Segment key field identifier |
Not Applicable |
5 |
| 09/21/2023 |
3.13.0 |
PRV.005.077 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/21/2023 |
3.13.0 |
PRV.005.076 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/14/2023 |
3.12.0 |
PRV.005.074 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
PRV.004.070 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
PRV.004.069 |
UPDATE |
Segment key field identifier |
Not Applicable |
6 |
| 09/21/2023 |
3.13.0 |
PRV.004.068 |
UPDATE |
Segment key field identifier |
Not Applicable |
5 |
| 09/21/2023 |
3.13.0 |
PRV.004.067 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/21/2023 |
3.13.0 |
PRV.004.065 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
PRV.004.064 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/14/2023 |
3.12.0 |
PRV.004.062 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
PRV.003.058 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 08/15/2023 |
3.12.0 |
PRV.003.054 |
UPDATE |
Coding requirement |
1. Must contain the '@' symbol2. May contain uppercase and lowercase Latin letters A to Z and a to z3. May contain digits 0-94. Must contain a dot '.' that is not the first or last character and provided that it does not appear consecutively5. Value must be 60 characters or less6. Optional |
1. Must contain the '@' symbol2. May contain uppercase and lowercase Latin letters A to Z and a to z3. May contain digits 0-94. Must contain a dot '.' that is not the first or last character and provided that it does not appear consecutively5. Value must be 60 characters or less6. Situational |
| 08/15/2023 |
3.12.0 |
PRV.003.053 |
UPDATE |
Coding requirement |
1. Value must be 10-digit number2. Optional |
1. Value must be 10-digit number2. Situational |
| 09/21/2023 |
3.13.0 |
PRV.003.052 |
UPDATE |
Medicaid valid value info |
|
Zip Code List |
| 08/14/2023 |
3.12.0 |
PRV.003.049 |
UPDATE |
Coding requirement |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 (CE) or Address Line 2 (CE) value(s)3. If Address Line 2 is not populated, then value should not be populated4. Value must not contain a pipe or asterisk symbols5. Conditional |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 or Address Line 2 value(s)3. If Address Line 2 is not populated, then value should not be populated4. Value must not contain a pipe or asterisk symbols5. Conditional |
| 08/14/2023 |
3.12.0 |
PRV.003.048 |
UPDATE |
Coding requirement |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 (CE) or Address Line 3 (CE) value(s)3. There must be an Address Line 1 (CE) in order to have an Address Line 2 (CE)4. Value must not contain a pipe or asterisk symbols5. Conditional |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 or Address Line 3 value(s)3. There must be an Address Line 1 in order to have an Address Line 24. Value must not contain a pipe or asterisk symbols5. Conditional |
| 08/14/2023 |
3.12.0 |
PRV.003.047 |
UPDATE |
Coding requirement |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 2 (CE) or Address Line 3 (CE) value(s)3. Value must not contain a pipe or asterisk symbols4. Mandatory5. When populated, the associated Address Type is required |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 2 or Address Line 3 value(s)3. Value must not contain a pipe or asterisk symbols4. Mandatory5. When populated, the associated Address Type is required |
| 09/21/2023 |
3.13.0 |
PRV.003.046 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/21/2023 |
3.13.0 |
PRV.003.044 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
PRV.003.043 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/14/2023 |
3.12.0 |
PRV.003.041 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
PRV.002.037 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 08/28/2023 |
3.12.0 |
PRV.002.035 |
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. Conditional4. If populated, value must be on or after individual's Date of Birth5. Value must be less than or equal to associated End of Time Period (PRV.001.010)6. There can only be one value on all records when the value is populated7. When populated, the difference between value and Date of Birth (PRV.002.034) must be 18 years or greater |
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. Conditional4. When populated, value must be on or after individual's Date of Birth5. Value must be less than or equal to associated End of Time Period (PRV.001.010)6. There can only be one value on all records when the value is populated7. When populated, the difference between value and Date of Birth (PRV.002.034) must be 18 years or greater |
| 08/28/2023 |
3.12.0 |
PRV.002.026 |
UPDATE |
Coding requirement |
1. Value must be in Facility Group Individual Code List (VVL)2. Value must be 2 characters3. Mandatory4. (individual) if value equals '03', then Provider First Name (PRV.002.028) must be populated5. (organization) if value does not equal '03', then Provider Middle Initial (PRV.002.029) must not be populated6. (individual) if value equals '03', then Provider Last Name (PRV.002.030) must be populated7. (individual) if value equals '03', then Provider Sex (PRV.002.031) must be populated8. (individual) if value equals '03', then Provider Date of Birth (PRV.002.034) must be populated9. (organization) if value equals '01' or '02', then Provider Date of Death (PRV.002.035) must not be populated |
1. Value must be in Facility Group Individual Code List (VVL)2. Value must be 2 characters3. Mandatory4. (individual) if value equals '03', then Provider First Name (PRV.002.028) must be populated5. (organization) if value does not equal '03', then Provider Middle Initial (PRV.002.029) must not be populated6. (individual) if value equals '03', then Provider Last Name (PRV.002.030) must be populated7. (individual) if value equals '03', then Provider Sex (PRV.002.031) must be populated8. (individual) if value equals '03', then Provider Date of Birth (PRV.002.034) must be populated9. (organization) if value equals '01' or '02', then Provider Date of Death (PRV.002.035) must not be populated10. (individual) if value equals '03', then there must be one Provider Identifier (PRV.005.081) populated with an associated Provider Identifier Type (PRV.005.077) equal to ‘2’ (NPI) |
| 08/09/2023 |
3.11.0 |
PRV.002.024 |
UPDATE |
Definition |
The name of the provider when the provider is an organization. If the provider organization name exceeds 60 characters submit only the first 60 characters of the name. |
The name of the provider when the provider is an organization. If the provider organization name exceeds 60 characters submit only the first 60 characters of the name. Provider Organization Name should be same as provider last name when provider is an individual. |
| 09/21/2023 |
3.13.0 |
PRV.002.020 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
PRV.002.019 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 08/14/2023 |
3.12.0 |
PRV.002.018 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
PRV.001.014 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 08/14/2023 |
3.12.0 |
PRV.001.010 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be equal to or after associated Start of Time Period (CE)6. Mandatory |
1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be equal to or after associated Start of Time Period6. Mandatory |
| 08/14/2023 |
3.12.0 |
PRV.001.009 |
UPDATE |
Coding requirement |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be before associated End of Time Period (CE)6. Mandatory |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be before associated End of Time Period6. Mandatory |
| 08/14/2023 |
3.12.0 |
PRV.001.008 |
UPDATE |
Coding requirement |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period (CE)6. Mandatory |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period6. Mandatory |
| 08/28/2023 |
3.12.0 |
PRV.001.002 |
UPDATE |
Coding requirement |
1. Value must be 10 characters or less2. Value must not include the pipe ("|") symbol3. Mandatory |
1. Value must be 10 characters or less2. Value must be in the Data Dictionary Version List (VVL)3. Mandatory |
| 08/21/2023 |
3.12.0 |
MCR.007.089 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
MCR.007.087 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 08/14/2023 |
3.12.0 |
MCR.007.084 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
MCR.006.080 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
MCR.006.078 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
MCR.006.077 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/14/2023 |
3.12.0 |
MCR.006.075 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
MCR.005.071 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
MCR.005.069 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
MCR.005.068 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/21/2023 |
3.13.0 |
MCR.005.067 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 09/21/2023 |
3.13.0 |
MCR.005.066 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 08/14/2023 |
3.12.0 |
MCR.005.065 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
MCR.004.061 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
MCR.004.059 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 08/14/2023 |
3.12.0 |
MCR.004.056 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
MCR.003.052 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 08/28/2023 |
3.12.0 |
MCR.003.051 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
MCR.003.051 |
UPDATE |
Coding requirement |
Optional |
1. Value must be a 10-digit number2. Situational |
| 08/28/2023 |
3.12.0 |
MCR.003.050 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
MCR.003.050 |
UPDATE |
Coding requirement |
1. Must contain the '@' symbol2. May contain uppercase and lowercase Latin letters A to Z and a to z3. May contain digits 0-94. Must contain a dot '.' that is not the first or last character and provided that it does not appear consecutively5. Value must be 60 characters or less6. Optional |
Must contain the '@' symbol2. May contain uppercase and lowercase Latin letters A to Z and a to z3. May contain digits 0-94. Must contain a dot '.' that is not the first or last character and provided that it does not appear consecutively5. Value must be 60 characters or less6. Situational |
| 08/28/2023 |
3.12.0 |
MCR.003.049 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
MCR.003.049 |
UPDATE |
Coding requirement |
1. Value must be 10-digit number2. Optional |
1. Value must be 10-digit number2. Situational |
| 09/21/2023 |
3.13.0 |
MCR.003.047 |
UPDATE |
Medicaid valid value info |
|
Zip Code List |
| 08/14/2023 |
3.12.0 |
MCR.003.043 |
UPDATE |
Coding requirement |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 (CE) or Address Line 3 (CE) value(s)3. There must be an Address Line 1 (CE) in order to have an Address Line 2 (CE)4. Value must not contain a pipe or asterisk symbols5. Conditional |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 or Address Line 3 value(s)3. There must be an Address Line 1 in order to have an Address Line 24. Value must not contain a pipe or asterisk symbols5. Conditional |
| 08/14/2023 |
3.12.0 |
MCR.003.042 |
UPDATE |
Coding requirement |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 2 (CE) or Address Line 3 (CE) value(s)3. Value must not contain a pipe or asterisk symbols4. Mandatory5. When populated, the associated Address Type is required |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 2 or Address Line 3 value(s)3. Value must not contain a pipe or asterisk symbols4. Mandatory5. When populated, the associated Address Type is required |
| 09/21/2023 |
3.13.0 |
MCR.003.041 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/21/2023 |
3.13.0 |
MCR.003.039 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
MCR.003.038 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/14/2023 |
3.12.0 |
MCR.003.036 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
MCR.002.032 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
MCR.002.030 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
MCR.002.024 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 09/21/2023 |
3.13.0 |
MCR.002.019 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 08/14/2023 |
3.12.0 |
MCR.002.018 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
MCR.001.014 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 08/14/2023 |
3.12.0 |
MCR.001.010 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be equal to or after associated Start of Time Period (CE)6. Mandatory |
1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be equal to or after associated Start of Time Period6. Mandatory |
| 08/14/2023 |
3.12.0 |
MCR.001.009 |
UPDATE |
Coding requirement |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be before associated End of Time Period (CE)6. Mandatory |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be before associated End of Time Period6. Mandatory |
| 08/14/2023 |
3.12.0 |
MCR.001.008 |
UPDATE |
Coding requirement |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period (CE)6. Mandatory |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period6. Mandatory |
| 08/28/2023 |
3.12.0 |
MCR.001.002 |
UPDATE |
Coding requirement |
1. Value must be 10 characters or less2. Value must not include the pipe ("|") symbol3. Mandatory |
1. Value must be 10 characters or less2. Value must be in the Data Dictionary Version List (VVL)3. Mandatory |
| 08/21/2023 |
3.12.0 |
ELG.022.267 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 08/28/2023 |
3.12.0 |
ELG.022.265 |
UPDATE |
Coding requirement |
1. Value must be 20 characters or less2. Mandatory3. Must not contain a pipe symbol |
1. Value must be 20 characters or less2. Mandatory3. Must not contain a pipe or asterisk symbol |
| 09/21/2023 |
3.13.0 |
ELG.022.263 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
ELG.022.261 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 07/13/2023 |
3.10.0 |
ELG.022.260 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 08/14/2023 |
3.12.0 |
ELG.022.259 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
ELG.021.255 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
ELG.021.253 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
ELG.021.252 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/14/2023 |
3.12.0 |
ELG.021.250 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
ELG.020.245 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
ELG.020.243 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
ELG.020.242 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/14/2023 |
3.12.0 |
ELG.020.240 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
ELG.018.236 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
ELG.018.234 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 08/01/2023 |
3.11.0 |
ELG.018.233 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Conditional |
| 08/14/2023 |
3.12.0 |
ELG.018.231 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
ELG.017.227 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
ELG.017.225 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
ELG.017.224 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/14/2023 |
3.12.0 |
ELG.017.222 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
ELG.016.218 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
ELG.016.216 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 08/01/2023 |
3.11.0 |
ELG.016.215 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in American Indian Alaskan Native Indicator List (VVL)4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in American Indian Alaskan Native Indicator List (VVL)4. Conditional |
| 09/21/2023 |
3.13.0 |
ELG.016.214 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/21/2023 |
3.13.0 |
ELG.016.213 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/14/2023 |
3.12.0 |
ELG.016.211 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/28/2023 |
3.12.0 |
ELG.015.271 |
UPDATE |
Coding requirement |
1. Value must be 25 characters or less2. Value is required when Ethnicity Code (ELG.015.204) equals '4' (Other)3. Conditional |
1. Value must be 25 characters or less2. If associated Ethnicity Code (ELG.015.204) is in ["4"], then value must be populated. 3. Conditional |
| 08/21/2023 |
3.12.0 |
ELG.015.207 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
ELG.015.205 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
ELG.015.204 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/14/2023 |
3.12.0 |
ELG.015.202 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
ELG.014.198 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
ELG.014.193 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/21/2023 |
3.13.0 |
ELG.014.192 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/14/2023 |
3.12.0 |
ELG.014.190 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
ELG.013.186 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
ELG.013.184 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 08/28/2023 |
3.12.0 |
ELG.013.183 |
UPDATE |
Coding requirement |
1. Value must be 30 characters or less2. Mandatory |
1. Value must be 30 characters or less2. Mandatory3. Value must match a corresponding Provider Identifier (PRV.005.081) |
| 09/21/2023 |
3.13.0 |
ELG.013.182 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/14/2023 |
3.12.0 |
ELG.013.180 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
ELG.012.176 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
ELG.012.174 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 08/15/2023 |
3.12.0 |
ELG.012.172 |
UPDATE |
Coding requirement |
1. Value must be associated with a populated Waiver Type (CE)2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Value must have a corresponding value in Waiver Type (ELG.012.173)6. Mandatory |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Value must have a corresponding value in Waiver Type (ELG.012.173)6. Mandatory |
| 08/14/2023 |
3.12.0 |
ELG.012.170 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
ELG.011.166 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
ELG.011.164 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
ELG.011.163 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/14/2023 |
3.12.0 |
ELG.011.161 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
ELG.010.157 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 08/14/2023 |
3.12.0 |
ELG.010.148 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 07/12/2023 |
3.10.0 |
ELG.009.270 |
UPDATE |
Coding requirement |
1. Value must be 3 characters2. Conditional |
1. Value must be 3 characters2. Conditional3. Must be a 3 digit value from the Type-of-Service valid value list |
| 08/21/2023 |
3.12.0 |
ELG.009.144 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
ELG.009.142 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
ELG.009.141 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 08/28/2023 |
3.12.0 |
ELG.009.140 |
UPDATE |
Coding requirement |
1. Value must be 30 characters or less2. Mandatory |
1. Value must be 30 characters or less2. Mandatory3. Value must match a corresponding Provider Identifier (PRV.005.081) |
| 08/14/2023 |
3.12.0 |
ELG.009.138 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
ELG.008.134 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
ELG.008.132 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
ELG.008.131 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/21/2023 |
3.13.0 |
ELG.008.130 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/14/2023 |
3.12.0 |
ELG.008.128 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
ELG.007.124 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
ELG.007.121 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
ELG.007.120 |
UPDATE |
Segment key field identifier |
Not Applicable |
5 |
| 09/21/2023 |
3.13.0 |
ELG.007.119 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/21/2023 |
3.13.0 |
ELG.007.118 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/14/2023 |
3.12.0 |
ELG.007.116 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
ELG.006.112 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
ELG.006.109 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
ELG.006.108 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/21/2023 |
3.13.0 |
ELG.006.107 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/14/2023 |
3.12.0 |
ELG.006.105 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
ELG.005.101 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 01/09/2023 |
3.2.0 |
ELG.005.095 |
UPDATE |
Definition |
The reason for a complete loss/termination in an individual's eligibility for Medicaid and CHIP. The end date of the segment in which the value is reported must represent the date that the complete loss/termination of Medicaid and CHIP eligibility occurred. The reason for the termination represents the reason that the segment in which it was reported was closed. |
The reason for a complete loss/termination in an individual's eligibility for Medicaid and CHIP. The end date of the segment in which the value is reported must represent the date that the complete loss/termination of Medicaid and CHIP eligibility occurred. The reason for the termination represents the reason that the segment in which it was reported was closed. If for a single termination in eligibility for a single individual, there are multiple distinct co-occurring values in the state's system explaining the reason for the termination, and if one of the multiple co-occurring values maps to T-MSIS ELIGIBILITY-CHANGE-REASON value '21' (Other) or '22' (Unknown), then the state should not report the co-occurring value '21' and/or '22' to T-MSIS. If there are multiple co-occurring distinct values between '01' and '19', then the state should choose whichever is first in the state's system. Of the values that could logically co-occur in the range of '01' through '19', CMS does not currently have a preference for any one value over another. |
| 08/16/2023 |
3.12.0 |
ELG.005.094 |
UPDATE |
Coding requirement |
1. Value must be in Conception to Birth Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If the value is equal to "1", then the Eligibility Group (ELG.005.087) must equal "64"5. If the value is equal to "1", then any associated claims must indicate the Program Type = '14' (State Plan CHIP)6. If the value is equal to "1", then CHIP Code (ELG.003.054) must equal "3" (Individual was not Medicaid Expansion CHIP eligible, but was included in a separate title XXI CHIP Program)7. Value must be 1 character8. Conditional |
1. Value must be in Conception to Birth Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If the value is equal to "1", then the Eligibility Group (ELG.005.087) must equal "64"5. If the value is equal to "1", then any associated claims must indicate the Program Type = '14' (State Plan CHIP)6. If the value is equal to "1", then CHIP Code (ELG.003.054) must equal "3" (Individual was not Medicaid Expansion CHIP eligible, but was included in a separate title XXI CHIP Program)7. Conditional |
| 09/21/2023 |
3.13.0 |
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" |
| 09/21/2023 |
3.13.0 |
ELG.005.089 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in SSDI Indicator List (VVL)4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in SSDI Indicator List (VVL)4. Conditional |
| 08/28/2023 |
3.12.0 |
ELG.005.087 |
UPDATE |
Coding requirement |
1. Value must be in Eligibility Group List (VVL)2. If value is "26", then Dual Eligible Code value must be "06"3. Conditional4. Value is mandatory and must be provided when associated Eligibility Determinant Effective Date value is on or after 1 January, 2014.5. If value is in [ "72", "73", "74", "75" ], then associated Restricted Benefits Code value must equal "1" or "7" and State Plan Option Type must equal "06"6. If associated CHIP Code value is "2", then value must be in [ "07", 31", "61" ]7. If associated CHIP Code value is "3", then value must be in [ "61", "62", "63", "64", "65", "66", "67", "68" ]8. Value must be 2 characters9. If value is "23", then Dual Eligible Code value must be in ["01", "02"]10. If value is "25", then Dual Eligible Code value must be in ["03", "04"]11. If value is "24", then Dual Eligible Code value must be "05" |
Value must be in Eligibility Group List (VVL)2. If value is "26", then Dual Eligible Code value must be "06"3. Conditional4. Value is mandatory and must be provided when associated Eligibility Determinant Effective Date value is on or after 1 January, 2014.5. If value is in [ "72", "73", "74", "75" ], then associated Restricted Benefits Code value must equal "1" or "7" and State Plan Option Type must equal "06"6. If associated CHIP Code value is "2", then value must be in [ "07", 31", "61" ]7. If associated CHIP Code value is "3", then value must be in [ "61", "62", "63", "64", "65", "66", "67", "68" ]8. Value must be 2 characters9. If value is "23", then Dual Eligible Code value must be in ["01", "02"]10. If value is "25", then Dual Eligible Code value must be in ["03", "04"]11. If value is "24", then Dual Eligible Code value must be "05"12. If value is "26", then Dual Eligible Code value must be "06" |
| 05/31/2023 |
3.8.0 |
ELG.005.085 |
UPDATE |
Necessity |
Conditional |
Mandatory |
| 05/31/2023 |
3.8.0 |
ELG.005.085 |
UPDATE |
Coding requirement |
1. Value must be in Dual Eligible Code List (VVL)2. If value is "05", then Eligibility Group (ELG.005.087) must be "24"3. If value is "06", then Eligibility Group (ELG.005.087) must be "26"4. If Dual Eligible Code (ELG.005.085) is "01", "02", "03", 04", 05", "06", "08", "09", or "10", then Primary Eligibility Group Indicator (ELG.005.086) must be "1" (Yes)5. Conditional6. A partial dual eligible (values="01', "03", "05" or "06") then Restricted Benefits Code (ELG.005.097) must be "3"7. (Not Dual Eligible) if value = "00", then associated Medicare Beneficiary Identifier (ELG.003.051) value must not be populated.8. Value must be 2 characters9. If value is in ["08", "10"] then Restricted Benefits Code (ELG.005.097) must be "1"10. If value is "09", then Eligibility Group (ELG.005.087) and Restricted Benefits Code (ELG.005.097) must not be populated11. If value equals "10", then CHIP Code (ELG.003.054) must be "03" (S-CHIP) and Medicare Beneficiary Identifier (ELG.003.051) must be populated12. If value is "01", then Eligibility Group (ELG.005.087) must be "23"13. If value is "03", then Eligibility Group (ELG.005.087) must be "25" |
1. Value must be in Dual Eligible Code List (VVL)2. If value is "05", then Eligibility Group (ELG.005.087) must be "24"3. If value is "06", then Eligibility Group (ELG.005.087) must be "26"4. If Dual Eligible Code (ELG.005.085) is "01", "02", "03", 04", 05", "06", "08", "09", or "10", then Primary Eligibility Group Indicator (ELG.005.086) must be "1" (Yes)5. Mandatory6. A partial dual eligible (values="01', "03", "05" or "06") then Restricted Benefits Code (ELG.005.097) must be "3"7. (Not Dual Eligible) if value = "00", then associated Medicare Beneficiary Identifier (ELG.003.051) value must not be populated.8. Value must be 2 characters9. If value is in ["08", "10"] then Restricted Benefits Code (ELG.005.097) must be "1"10. If value is "09", then Eligibility Group (ELG.005.087) and Restricted Benefits Code (ELG.005.097) must not be populated11. If value equals "10", then CHIP Code (ELG.003.054) must be "03" (S-CHIP) and Medicare Beneficiary Identifier (ELG.003.051) must be populated12. If value is "01", then Eligibility Group (ELG.005.087) must be "23"13. If value is "03", then Eligibility Group (ELG.005.087) must be "25" |
| 09/21/2023 |
3.13.0 |
ELG.005.083 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/14/2023 |
3.12.0 |
ELG.005.081 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
ELG.004.077 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
ELG.004.075 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 08/09/2023 |
3.11.0 |
ELG.004.074 |
UPDATE |
Definition |
A free-form text field to describe the type of living arrangement used for the eligibility determination process. The field will remain a free-form text data element until MACPro develops a list of valid values. When it becomes available, T-MSIS will align with MACPro valid value lists. |
A free-form text field to describe the type of living arrangement used for the eligibility determination process. |
| 08/28/2023 |
3.12.0 |
ELG.004.073 |
UPDATE |
Coding requirement |
1. Value must be 10-digit number2. Conditional |
1. Value must be 10-digit number2. Conditional3. If Eligible Address Type (ELG.004.065) = ''01', then value is mandatory and must be provided |
| 08/14/2023 |
3.12.0 |
ELG.004.068 |
UPDATE |
Coding requirement |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 (CE) or Address Line 2 (CE) value(s)3. If Address Line 2 is not populated, then value should not be populated4. Value must not contain a pipe or asterisk symbols5. Conditional |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 or Address Line 2 value(s)3. If Address Line 2 is not populated, then value should not be populated4. Value must not contain a pipe or asterisk symbols5. Conditional |
| 08/14/2023 |
3.12.0 |
ELG.004.067 |
UPDATE |
Coding requirement |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 (CE) or Address Line 3 (CE) value(s)3. There must be an Address Line 1 (CE) in order to have an Address Line 2 (CE)4. Value must not contain a pipe or asterisk symbols5. Conditional |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 or Address Line 3 value(s)3. There must be an Address Line 1 in order to have an Address Line 24. Value must not contain a pipe or asterisk symbols5. Conditional |
| 08/14/2023 |
3.12.0 |
ELG.004.066 |
UPDATE |
Coding requirement |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 2 (CE) or Address Line 3 (CE) value(s)3. Value must not contain a pipe or asterisk symbols4. Mandatory5. When populated, the associated Address Type is required |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 2 or Address Line 3 value(s)3. Value must not contain a pipe or asterisk symbols4. Mandatory5. When populated, the associated Address Type is required |
| 09/21/2023 |
3.13.0 |
ELG.004.065 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/14/2023 |
3.12.0 |
ELG.004.063 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 07/14/2023 |
3.10.0 |
ELG.003.269 |
UPDATE |
Definition |
This data element provides the beneficiary's or their household's income as a percentage of the federal poverty level. Used to assign the beneficiary to the eligibility group that covered their Medicaid or CHIP benefits. If the beneficiary's income was assessed using
multiple methodologies (MAGI and Non-MAGI), report the one that applies to their primary eligibility group. |
This data element provides the beneficiary's or their household's income as a percentage of the federal poverty level. Used to assign the beneficiary to the eligibility group that covered their Medicaid or CHIP benefits. If the beneficiary's income was assessed using multiple methodologies (MAGI and Non-MAGI), report the income that applies to their primary eligibility group.A beneficiary’s income is applicable unless it is not required by the eligibility group for which they were determined eligible. For example, the eligibility groups for children with adoption assistance, foster care, or guardianship care under title IV-E and optional eligibility for individuals needing treatment for breast or cervical cancer do not have a Medicaid income test. Additionally, for individuals receiving SSI, states with section 1634 agreements with the Social Security Administration (SSA) and states that use SSI financial methodologies for Medicaid determinations do not conduct separate Medicaid financial eligibility for this group. |
| 08/21/2023 |
3.12.0 |
ELG.003.059 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 08/01/2023 |
3.11.0 |
ELG.003.049 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Pregnancy Indicator List (VVL)4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Pregnancy Indicator List (VVL)4. Conditional |
| 07/12/2023 |
3.10.0 |
ELG.003.040 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Citizenship Indicator List (VVL)4. If value is coded as '0', then associated Immigration Status (ELG.003.042) value must be in [ 1, 2, 3 ]5. If value is coded as '1', then associated Immigration Status (ELG.003.042) value must equal '8'6. Value must be 1 character7. Mandatory |
1. Value must be 1 character2. Value must be in [0, 1, 2] or not populated3. Value must be in Citizenship Indicator List (VVL)4. If value is coded as '0', then associated Immigration Status (ELG.003.042) value must be in [ 1, 2, 3 ]5. If value is coded as '1', then associated Immigration Status (ELG.003.042) value must equal '8'6. Value must be 1 character7. Mandatory |
| 08/28/2023 |
3.12.0 |
ELG.003.039 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Veteran Indicator List (VVL)4. Value must be 1 character5. Conditional6. Value must be populated when Immigration Status (ELG.003.042) is in ['1', '2', '3'] |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Veteran Indicator List (VVL)4. Conditional5. Value must be populated when Immigration Status (ELG.003.042) is in ['1', '2', '3'] |
| 05/10/2023 |
3.7.0 |
ELG.003.038 |
UPDATE |
Necessity |
Mandatory |
Conditional |
| 05/10/2023 |
3.7.0 |
ELG.003.038 |
UPDATE |
Coding requirement |
1. Value must be in Income Code List (VVL)2. Value must be 2 characters3. Mandatory |
1. Value must be in Income Code List (VVL)2. Value must be 2 characters3. Conditional |
| 06/21/2023 |
3.9.0 |
ELG.003.034 |
UPDATE |
Definition |
A code to classify eligible individual's marital/domestic-relationship status. An eligible individual who is younger than 12 years should have a marital status of never married or
unknown. This element should be reported by the state when the information is material to eligibility (i.e., institutionalization). |
A code to classify eligible individual's marital/domestic-relationship status. This element should be reported by the state when the information is material to eligibility (i.e., institutionalization).Because there is no specific statutory or regulatory basis for defining marital status codes, they are being defined in a way that is as flexible for states and data users as possible. States can report at whatever level of granularity is available to them in their system and a data user can choose to use them as-is or roll the values up in broader categories depending on whichever approach best meets their needs. CMS periodically reviews the values reported to MARITAL-STATUS-OTHER-EXPLANATION to determine if states are appropriately using it only when there is no existing MARITAL-STATUS value that reflects the state’s marital status description for an individual AND to determine whether it is necessary to add additional T-MSIS MARITAL-STATUS values to reflect commonly used state martial status descriptions for which there is no existing T-MSIS MARITAL-STATUS value. |
| 08/14/2023 |
3.12.0 |
ELG.003.032 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
ELG.002.028 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
ELG.002.026 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 08/14/2023 |
3.12.0 |
ELG.002.024 |
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. Children enrolled in the Separate CHIP prenatal program option should have a date of birth missing or a date of birth equal to the pregnant mother's date of birth4. When Conception to Birth Indicator (ELG.005.094) does not equal '1' and Eligibility Group (ELG.005.087) does not equal '64' value must be less than or equal to associated End of Time Period (CE) value5. Value must be less than or equal to associated Date File Created (ELG.001.008) value6. Mandatory7. When Conception to Birth Indicator (ELG.005.094) does not equal '1' and Eligibility Group (ELG.005.087) does not equal '64' value minus Start of Time Period (ELG.001.10) must be less than 125 years |
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. Children enrolled in the Separate CHIP prenatal program option should have a date of birth missing or a date of birth equal to the pregnant mother's date of birth4. When Conception to Birth Indicator (ELG.005.094) does not equal '1' and Eligibility Group (ELG.005.087) does not equal '64' value must be less than or equal to associated End of Time Period value5. Value must be less than or equal to associated Date File Created (ELG.001.008) value6. Mandatory7. When Conception to Birth Indicator (ELG.005.094) does not equal '1' and Eligibility Group (ELG.005.087) does not equal '64' value minus Start of Time Period (ELG.001.10) must be less than 125 years |
| 07/13/2023 |
3.10.0 |
ELG.002.019 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 08/14/2023 |
3.12.0 |
ELG.002.018 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
ELG.001.014 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 08/14/2023 |
3.12.0 |
ELG.001.009 |
UPDATE |
Coding requirement |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be before associated End of Time Period (CE)6. Mandatory |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be before associated End of Time Period6. Mandatory |
| 08/14/2023 |
3.12.0 |
ELG.001.008 |
UPDATE |
Coding requirement |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period (CE)6. Mandatory |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period6. Mandatory |
| 08/28/2023 |
3.12.0 |
ELG.001.002 |
UPDATE |
Coding requirement |
1. Value must be 10 characters or less2. Value must not include the pipe ("|") symbol3. Mandatory |
1. Value must be 10 characters or less2. Value must be in the Data Dictionary Version List (VVL)3. Mandatory |
| 02/16/2023 |
3.3.0 |
CRX.003.172 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated |
1. Value must be 1 character2. Value must be in [0, 1] |
| 09/21/2023 |
3.13.0 |
CRX.003.157 |
UPDATE |
Segment key field identifier |
Not Applicable |
7 |
| 08/21/2023 |
3.12.0 |
CRX.003.153 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/01/2023 |
3.12.0 |
CRX.003.127 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional4. Value should not be populated if associated Crossover Indicator value is '0' (not a crossover claim)5. If value is greater than '0,' then Crossover Indicator must be '1' |
Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional4. If associated Crossover Indicator value is '0' (not a crossover claim), value should not be populated5. If value is greater than '0,' then Crossover Indicator must be '1' |
| 08/14/2023 |
3.12.0 |
CRX.003.126 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Type of Claim (CE) value equals '3, C, W', then value is mandatory and must be provided4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Type of Claim value equals '3, C, W', then value is mandatory and must be provided4. Conditional |
| 08/09/2023 |
3.11.0 |
CRX.003.125 |
UPDATE |
Definition |
The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. |
The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 08/28/2023 |
3.12.0 |
CRX.003.123 |
UPDATE |
Necessity |
Conditional |
Situational |
| 08/28/2023 |
3.12.0 |
CRX.003.123 |
UPDATE |
Coding requirement |
1. Conditional2. Value must be 5 digits or less left of the decimal i.e. 99999.99 |
1. Situational2. Value must be 5 digits or less left of the decimal i.e. 99999.99 |
| 08/09/2023 |
3.11.0 |
CRX.003.122 |
UPDATE |
Definition |
The maximum amount displayed at the claim line level as determined by the payer as being "allowable" under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed
care encounters the Allowed Amount is determined by the managed care organization. |
The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed care encounters the Allowed Amount is determined by the managed care organization.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity allowed at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 08/09/2023 |
3.11.0 |
CRX.003.121 |
UPDATE |
Definition |
The amount billed at the claim detail level as submitted by the provider. For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed the managed care plan. |
The amount billed at the claim detail level as submitted by the provider. For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed the managed care plan.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the provider billed the sub-capitated entity at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 09/01/2023 |
3.12.0 |
CRX.003.120 |
UPDATE |
Coding requirement |
1. Value must be 12 digits or less2. Value must be a valid National Drug Code3. Mandatory4. Value must have an associated Metric Decimal Quantity (CRX.003.144)5. Value must have an associated Unit of Measure (CRX.003.133) |
1. Value must be 12 digits or less2. Value must be a valid National Drug Code3. Mandatory4. Value must have an associated Dtl Metric Decimal Quantity (CRX.003.144)5. Value must have an associated Unit of Measure (CRX.003.133) |
| 09/21/2023 |
3.13.0 |
CRX.003.115 |
UPDATE |
Segment key field identifier |
Not Applicable |
5 |
| 09/21/2023 |
3.13.0 |
CRX.003.114 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 08/28/2023 |
3.12.0 |
CRX.003.113 |
UPDATE |
Coding requirement |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [‘4’, ‘1’] then value must be populated |
| 09/21/2023 |
3.13.0 |
CRX.003.112 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 07/13/2023 |
3.10.0 |
CRX.003.111 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less5. When TYPE-OF-CLAIM = 4, D or X (lump sum payment), value must begin with an '&' |
1. Mandatory2. Value must be 20 characters or less3. When TYPE-OF-CLAIM = 4, D or X (lump sum payment), value must begin with an '&' |
| 08/14/2023 |
3.12.0 |
CRX.003.110 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/10/2023 |
3.11.0 |
CRX.002.165 |
UPDATE |
Definition |
The total deductible amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary deductible liability for covered services on the claim. Do not subtract out any payments made toward the
deductible. |
The total deductible amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary deductible liability minus previous beneficiary payments that went toward their deductible. Do not subtract out any payments for the given claim that went toward the deductible. |
| 08/10/2023 |
3.11.0 |
CRX.002.164 |
UPDATE |
Definition |
The total coinsurance amount on a claim that the beneficiary is obligated to pay for covered services. This is the total Medicaid or contract negotiated beneficiary coinsurance liability for covered service on the claim. Do not subtract out any payments made toward the
copayment. |
The total coinsurance amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary coinsurance liability for covered services on the claim. Do not subtract out any payments made toward the coinsurance. |
| 08/01/2023 |
3.11.0 |
CRX.002.160 |
UPDATE |
Coding requirement |
1. Value must be in Medicare Combined Deductible Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. Value must be 1 character5. If value equals '1', then Total Medicare Coinsurance amount must not be populated.6. If value equals '0', then Crossover Indicator must equals '0'7. If value equals '1', then Crossover Indicator must equals '1'8. Conditional |
1. Value must be in Medicare Combined Deductible Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If value equals '1', then Total Medicare Coinsurance amount must not be populated.5. If value equals '0', then Crossover Indicator must equals '0'6. If value equals '1', then Crossover Indicator must equals '1'7. Conditional |
| 08/21/2023 |
3.12.0 |
CRX.002.106 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 08/28/2023 |
3.12.0 |
CRX.002.104 |
UPDATE |
Coding requirement |
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. Conditional |
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 |
| 08/23/2023 |
3.12.0 |
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. Must have an associated Third Party Copayment Amount4. Optional |
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 Amount 4. Situational |
| 08/23/2023 |
3.12.0 |
CRX.002.100 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Optional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Situational |
| 08/23/2023 |
3.12.0 |
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. Must have an associated Third Party Coinsurance Amount4. Conditional |
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 Amount 4. Conditional |
| 08/23/2023 |
3.12.0 |
CRX.002.098 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Optional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Situational |
| 08/28/2023 |
3.12.0 |
CRX.002.095 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
CRX.002.095 |
UPDATE |
Coding requirement |
1. Value must be in Copay Waived Indicator List (VVL)2. Value must be 1 character3. Optional |
1. Value must be in Copay Waived Indicator List (VVL)2. Value must be 1 character3. Value must be in [0,1] or not populated4. Situational |
| 09/07/2023 |
3.12.0 |
CRX.002.092 |
UPDATE |
Definition |
The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their deductible for the covered services on the claim. Do not include deductible payments made by a third party/s on behalf of the beneficiary. |
The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their deductible for the covered services on the claim. Do not include deductible payments made by a third party/ies on behalf of the beneficiary. |
| 09/07/2023 |
3.12.0 |
CRX.002.089 |
UPDATE |
Definition |
The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on the claim. Do not include copayment payments made by a third party/s on behalf of the beneficiary. |
The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on the claim. Do not include copayment payments made by a third party/ies on behalf of the beneficiary. |
| 09/07/2023 |
3.12.0 |
CRX.002.087 |
UPDATE |
Definition |
The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their coinsurance for the covered services on the claim. Do not include coinsurance payments made by a third party/s on behalf of the beneficiary. |
The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their coinsurance for the covered services on the claim. Do not include coinsurance payments made by a third party/ies on behalf of the beneficiary. |
| 08/01/2023 |
3.11.0 |
CRX.002.082 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Border State Indicator List (VVL)4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Border State Indicator List (VVL)4. Conditional |
| 07/12/2023 |
3.10.0 |
CRX.002.081 |
UPDATE |
Definition |
The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The first five (5) positions are Julian date following a YYDDD format. The RA is the detailed
explanation of the reason for the payment amount. |
The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The RA is the detailed explanation of the reason for the payment amount. |
| 09/21/2023 |
3.13.0 |
CRX.002.075 |
UPDATE |
Coding requirement |
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. Mandatory |
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) |
| 08/15/2023 |
3.12.0 |
CRX.002.069 |
UPDATE |
Coding requirement |
1. Value must be associated with a populated Waiver Type (CE)2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Conditional |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Conditional |
| 08/28/2023 |
3.12.0 |
CRX.002.067 |
UPDATE |
Coding requirement |
1. Value must be in Health Home Provider Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If there is an associated Health Home Entity Name value, then value must be "1"5. Value must be 1 character6. Conditional |
1. Value must be in Health Home Provider Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If there is an associated Health Home Entity Name value, then value must be "1"5. Conditional |
| 08/01/2023 |
3.11.0 |
CRX.002.061 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Forced Claim Indicator List (VVL)4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Forced Claim Indicator List (VVL)4. Conditional |
| 08/14/2023 |
3.12.0 |
CRX.002.060 |
UPDATE |
Coding requirement |
1. Value must be a positive integer2. Value must be between 0:9999 (inclusive)3. Value must not include commas or other non-numeric characters4. Value must be equal to the number of claim lines (e.g. Original Claim Line Number (CE) or Adjustment Claim Line Number (CE) instances) reported in the associated claim record being reported5. Value must be 4 characters or less6. Mandatory |
1. Value must be a positive integer2. Value must be between 0:9999 (inclusive)3. Value must not include commas or other non-numeric characters4. Value must be equal to the number of claim lines (e.g. Original Claim Line Number or Adjustment Claim Line Number instances) reported in the associated claim record being reported5. Value must be 4 characters or less6. Mandatory |
| 06/14/2023 |
3.9.0 |
CRX.002.058 |
UPDATE |
Definition |
The field denotes whether the payment amount was determined at the claim header or line/detail level. |
The field denotes whether the payment amount was determined at the claim header or line/detail level.For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines’ associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only.For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header.For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed.For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
| 06/01/2023 |
3.8.0 |
CRX.002.054 |
UPDATE |
Coding requirement |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Conditional |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
| 05/31/2023 |
3.8.0 |
CRX.002.053 |
UPDATE |
Necessity |
Mandatory |
Conditional |
| 05/31/2023 |
3.8.0 |
CRX.002.053 |
UPDATE |
Coding requirement |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Mandatory |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Conditional |
| 08/01/2023 |
3.11.0 |
CRX.002.052 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Fixed Payment Indicator List (VVL)4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Fixed Payment Indicator List (VVL)4. Conditional |
| 08/01/2023 |
3.11.0 |
CRX.002.048 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Other Insurance Indicator List (VVL)4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Other Insurance Indicator List (VVL)4. Conditional |
| 08/15/2023 |
3.12.0 |
CRX.002.045 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than associated Total Billed Amount (CE) - (Total Medicare Coinsurance Amount (CE) + Total Medicare Deductible Amount (CE))4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than associated Total Billed Amount - (Total Medicare Coinsurance Amount + Total Medicare Deductible Amount)4. Conditional |
| 08/09/2023 |
3.11.0 |
CRX.002.040 |
UPDATE |
Definition |
The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. On managed care encounters the Allowed Amount is
determined by the managed care organization. |
The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. On managed care encounters the Allowed Amount is determined by the managed care organization.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity allowed for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 08/09/2023 |
3.11.0 |
CRX.002.032 |
UPDATE |
Definition |
The field denotes the claims payment system from which the claim was extracted. |
The field denotes the claims payment system from which the claim was extracted.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = '22' to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis.For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = '23' to indicate that the sub-capitated network provider provided the service directly to the enrollee.For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = “23” to indicate that the sub-capitated network provider provided the service directly to the enrollee. |
| 08/09/2023 |
3.11.0 |
CRX.002.029 |
UPDATE |
Definition |
A code to indicate what type of payment is covered in this claim. |
A code to indicate what type of payment is covered in this claim.For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record. |
| 01/05/2023 |
3.2.0 |
CRX.002.028 |
UPDATE |
Definition |
The date Medicaid paid this claim or adjustment. |
The date Medicaid paid this claim or adjustment. For Encounter Records (Type of Claim = 3, C, W), the date the managed care organization paid the provider for the claim or adjustment. |
| 09/21/2023 |
3.13.0 |
CRX.002.027 |
UPDATE |
Segment key field identifier |
Not Applicable |
5 |
| 08/01/2023 |
3.11.0 |
CRX.002.024 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Value must be 1 character5. Conditional6. When value equals '0', is invalid or not populated, the associated 1115A Demonstration Indicator (ELG.018.233) must equal '0', is invalid or not populated |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Conditional5. When value equals '0', is invalid or not populated, the associated 1115A Demonstration Indicator (ELG.018.233) must equal '0', is invalid or not populated |
| 08/28/2023 |
3.12.0 |
CRX.002.020 |
UPDATE |
Coding requirement |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [‘4’, ‘1’] then value must be populated |
| 09/21/2023 |
3.13.0 |
CRX.002.019 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 08/14/2023 |
3.12.0 |
CRX.002.018 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
CRX.001.014 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
CRX.001.012 |
UPDATE |
Coding requirement |
1. Value must be in SSN Indicator List (VVL)2. Value must be 1 character3. Mandatory |
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) |
| 08/14/2023 |
3.12.0 |
CRX.001.010 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be equal to or after associated Start of Time Period (CE)6. Mandatory |
1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be equal to or after associated Start of Time Period6. Mandatory |
| 08/14/2023 |
3.12.0 |
CRX.001.009 |
UPDATE |
Coding requirement |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be before associated End of Time Period (CE)6. Mandatory |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be before associated End of Time Period6. Mandatory |
| 08/14/2023 |
3.12.0 |
CRX.001.008 |
UPDATE |
Coding requirement |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period (CE)6. Mandatory |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period6. Mandatory |
| 08/28/2023 |
3.12.0 |
CRX.001.002 |
UPDATE |
Coding requirement |
1. Value must be 10 characters or less2. Value must not include the pipe ("|") symbol3. Mandatory |
1. Value must be 10 characters or less2. Value must be in the Data Dictionary Version List (VVL)3. Mandatory |
| 02/16/2023 |
3.3.0 |
COT.003.234 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated |
1. Value must be 1 character2. Value must be in [0, 1] |
| 09/21/2023 |
3.13.0 |
COT.003.221 |
UPDATE |
Segment key field identifier |
Not Applicable |
7 |
| 08/21/2023 |
3.12.0 |
COT.003.214 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
COT.003.208 |
UPDATE |
Medicaid valid value info |
|
Zip Code List |
| 08/14/2023 |
3.12.0 |
COT.003.205 |
UPDATE |
Coding requirement |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 (CE) or Address Line 3 (CE) value(s)3. There must be an Address Line 1 (CE) in order to have an Address Line 2 (CE)4. Value must not contain a pipe or asterisk symbols5. Conditional |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 or Address Line 3 value(s)3. There must be an Address Line 1 in order to have an Address Line 24. Value must not contain a pipe or asterisk symbols5. Conditional |
| 08/14/2023 |
3.12.0 |
COT.003.204 |
UPDATE |
Coding requirement |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 2 (CE) or Address Line 3 (CE) value(s)3. Value must not contain a pipe or asterisk symbols4. Conditional |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 2 or Address Line 3 value(s)3. Value must not contain a pipe or asterisk symbols4. Conditional |
| 09/21/2023 |
3.13.0 |
COT.003.203 |
UPDATE |
Medicaid valid value info |
|
Zip Code List |
| 08/14/2023 |
3.12.0 |
COT.003.200 |
UPDATE |
Coding requirement |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 (CE) or Address Line 3 (CE) value(s)3. There must be an Address Line 1 (CE) in order to have an Address Line 2 (CE)4. Value must not contain a pipe or asterisk symbols5. Conditional |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 or Address Line 3 value(s)3. There must be an Address Line 1 in order to have an Address Line 24. Value must not contain a pipe or asterisk symbols5. Conditional |
| 08/14/2023 |
3.12.0 |
COT.003.199 |
UPDATE |
Coding requirement |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 2 (CE) or Address Line 3 (CE) value(s)3. Value must not contain a pipe or asterisk symbols4. Conditional |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 2 or Address Line 3 value(s)3. Value must not contain a pipe or asterisk symbols4. Conditional |
| 09/07/2023 |
3.12.0 |
COT.003.184 |
UPDATE |
Definition |
The maximum allowable quantity of a service that may be rendered per date of service or per month. For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMOT claims/encounter records, use theRevenue center -quantity Allowedfield. NOTE: One prescription for 100 250 milligram tablets results inPrescription Quantity allowed=100.This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled. For prescriptions/refills, use the Medicaid Drug Rebate definition of a unit, which is the smallest unit by which the drug is normally measured; e.g. tablet, capsule, milliliter, etc. For drugs not identifiable or dispensed by a normal unit, e.g. powder filled vials, use 1 as the number of units. The value inPrescription Quantity allowedmust correspond with the value in Unit of measure. |
The maximum allowable quantity of a service that may be rendered per date of service or per month. For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMOT claims/encounter records, use the Revenue center -quantity Allowed field. NOTE: One prescription for 100 250 milligram tablets results in Prescription Quantity allowed=100.This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled. For prescriptions/refills, use the Medicaid Drug Rebate definition of a unit, which is the smallest unit by which the drug is normally measured; e.g. tablet, capsule, milliliter, etc. For drugs not identifiable or dispensed by a normal unit, e.g. powder filled vials, use 1 as the number of units. The value in Prescription Quantity allowed must correspond with the value in Unit of measure. |
| 09/07/2023 |
3.12.0 |
COT.003.183 |
UPDATE |
Definition |
The quantity of a service or product that is rendered for a specific date of service or billing time span as reported by revenue code or procedure code on the claim line. For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMOT claims/encounter records, use the Service Quantity Actual field. |
The quantity of a service or product that is rendered for a specific date of service or billing time span as reported by revenue code or procedure code on the claim line. For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMOT claims/encounter records, use the Service Quantity Actual field. This field is only applicable when the service being billed can be quantified in discrete units, e.g. a number of visits or the number of units of a prescription/refill that were filled. |
| 08/14/2023 |
3.12.0 |
COT.003.179 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Type of Claim (CE) value equals '3, C, W', then value is mandatory and must be provided4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Type of Claim value equals '3, C, W', then value is mandatory and must be provided4. Conditional |
| 08/09/2023 |
3.11.0 |
COT.003.178 |
UPDATE |
Definition |
The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. |
The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 08/16/2023 |
3.12.0 |
COT.003.176 |
UPDATE |
Coding requirement |
1. Conditional2. Value must be 11 digits or less left of the decimal i.e. 99999999999.99 |
1. Situational2. Value must be between -99999999999.99 and 99999999999.993. Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) |
| 08/09/2023 |
3.11.0 |
COT.003.175 |
UPDATE |
Definition |
The maximum amount displayed at the claim line level as determined by the payer as being "allowable" under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed
care encounters the Allowed Amount is determined by the managed care organization. |
The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed care encounters the Allowed Amount is determined by the managed care organization.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity allowed at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 08/09/2023 |
3.11.0 |
COT.003.174 |
UPDATE |
Definition |
The amount billed at the claim detail level as submitted by the provider. For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed the managed care plan. |
The amount billed at the claim detail level as submitted by the provider. For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed the managed care plan.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the provider billed the sub-capitated entity at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 09/21/2023 |
3.13.0 |
COT.003.161 |
UPDATE |
Segment key field identifier |
Not Applicable |
5 |
| 09/21/2023 |
3.13.0 |
COT.003.160 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 08/28/2023 |
3.12.0 |
COT.003.159 |
UPDATE |
Coding requirement |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [‘4’, ‘1’] then value must be populated |
| 09/21/2023 |
3.13.0 |
COT.003.158 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 07/13/2023 |
3.10.0 |
COT.003.157 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less5. When Type of Claim (COT.002.037) equals 4, D or X (lump sum payment) value must begin with an '&' |
1. Mandatory2. Value must be 20 characters or less3. When Type of Claim (COT.002.037) equals 4, D or X (lump sum payment) value must begin with an '&' |
| 08/14/2023 |
3.12.0 |
COT.003.156 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/10/2023 |
3.11.0 |
COT.002.232 |
UPDATE |
Definition |
The total deductible amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary deductible liability for covered services on the claim. Do not subtract out any payments made toward the
deductible. |
The total deductible amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary deductible liability minus previous beneficiary payments that went toward their deductible. Do not subtract out any payments for the given claim that went toward the deductible. |
| 08/10/2023 |
3.11.0 |
COT.002.231 |
UPDATE |
Definition |
The total coinsurance amount on a claim that the beneficiary is obligated to pay for covered services. This is the total Medicaid or contract negotiated beneficiary coinsurance liability for covered service on the claim. Do not subtract out any payments made toward the
copayment. |
The total coinsurance amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary coinsurance liability for covered services on the claim. Do not subtract out any payments made toward the coinsurance. |
| 05/31/2023 |
3.8.0 |
COT.002.229 |
UPDATE |
Definition |
The NPI of Ordering Provider represents the individual who requested the service or items being reported on this service line. Example include, but are not limited to, provider ordering diagnostic tests and medical equipment or supplies. |
A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).|Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm).The NPI of Ordering Provider represents the individual who requested the service or items being reported on this service line. Example include, but are not limited to, provider ordering diagnostic tests and medical equipment or supplies.[Ordering provider information is only captured at the line level in the X12 837P format but in v3.0.0 of the T-MSIS file layout it is only captured at the header level. This discrepancy will be addressed in a future version of the T-MSIS OT file layout. Until Ordering provider information has been moved from the T-MSIS claim header to the line, there is no need to report it at the header.] |
| 05/31/2023 |
3.8.0 |
COT.002.228 |
UPDATE |
Definition |
The Medicaid provider ID of the Ordering Provider is the individual who requested the services or items being reported on this service line. Examples include, but are not limited to, provider ordering diagnostic tests and medical equipment or supplies |
The Medicaid provider ID of the Ordering Provider is the individual who requested the services or items being reported on this service line. Examples include, but are not limited to, provider ordering diagnostic tests and medical equipment or supplies. [Ordering provider information is only captured at the line level in the X12 837P format but in v3.0.0 of the T-MSIS file layout it is only captured at the header level. This discrepancy will be addressed in a future version of the T-MSIS OT file layout. Until Ordering provider information has been moved from the T-MSIS claim header to the line, there is no need to report it at the header.] |
| 08/21/2023 |
3.12.0 |
COT.002.152 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 08/28/2023 |
3.12.0 |
COT.002.146 |
UPDATE |
Coding requirement |
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 Service (COT.003.186) equals '121', value must not be populated |
Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. When Type of Service (COT.003.186) equals '121', value must not be populated5. Value must exist in the NPPES NPI data file |
| 08/23/2023 |
3.12.0 |
COT.002.143 |
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. Must have an associated Third Party Copayment Amount4. Optional |
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 Amount 4. Situational |
| 08/23/2023 |
3.12.0 |
COT.002.142 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Optional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Situational |
| 08/23/2023 |
3.12.0 |
COT.002.141 |
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. Must have an associated Third Party Coinsurance Amount4. Conditional |
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 Amount 4. Conditional |
| 08/23/2023 |
3.12.0 |
COT.002.140 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Optional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Situational |
| 08/28/2023 |
3.12.0 |
COT.002.138 |
UPDATE |
Coding requirement |
1. Value must not contain a pipe or asterisk symbols2. Value must 50 characters or less3. Conditional |
1. Value must not contain a pipe or asterisk symbols2. Value must 50 characters or less3. Conditional4. Value must be populated when an associated Type of Service (COT.003.186) equals ‘138’ (payment for health home services)5. Value must be populated when an associated claim line has a XIX MBESCBES Category of Service (COT.003.211) equals ‘45’ (health homes for substance use services) |
| 08/28/2023 |
3.12.0 |
COT.002.137 |
UPDATE |
Necessity |
Not Applicable |
Situational |
| 08/28/2023 |
3.12.0 |
COT.002.137 |
UPDATE |
Coding requirement |
Optional |
1. Value must be in Copayment Waived Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1]4. Situational |
| 09/07/2023 |
3.12.0 |
COT.002.134 |
UPDATE |
Definition |
The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their deductible for the covered services on the claim. Do not include deductible payments made by a third party/s on behalf of the beneficiary. |
The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their deductible for the covered services on the claim. Do not include deductible payments made by a third party/ies on behalf of the beneficiary. |
| 09/07/2023 |
3.12.0 |
COT.002.132 |
UPDATE |
Definition |
The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on the claim. Do not include copayment payments made by a third party/s on behalf of the beneficiary. |
The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on the claim. Do not include copayment payments made by a third party/ies on behalf of the beneficiary. |
| 09/07/2023 |
3.12.0 |
COT.002.130 |
UPDATE |
Definition |
The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their coinsurance for the covered services on the claim. Do not include coinsurance payments made by a third party/s on behalf of the beneficiary. |
The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their coinsurance for the covered services on the claim. Do not include coinsurance payments made by a third party/ies on behalf of the beneficiary. |
| 08/01/2023 |
3.11.0 |
COT.002.128 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Border State Indicator List (VVL)4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Border State Indicator List (VVL)4. Conditional |
| 07/12/2023 |
3.10.0 |
COT.002.126 |
UPDATE |
Definition |
The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The first five (5) positions are Julian date following a YYDDD format. The RA is the detailed
explanation of the reason for the payment amount. |
The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The RA is the detailed explanation of the reason for the payment amount. |
| 08/28/2023 |
3.12.0 |
COT.002.118 |
UPDATE |
Coding requirement |
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. Conditional |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Value must be in the NPPES NPI data file4. Conditional |
| 08/28/2023 |
3.12.0 |
COT.002.109 |
UPDATE |
Coding requirement |
1. Value must be in Health Home Provider Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If there is an associated Health Home Entity Name value, then value must be "1"5. Value must be 1 character6. Conditional |
1. Value must be in Health Home Provider Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If there is an associated Health Home Entity Name value, then value must be "1"5. Conditional |
| 08/14/2023 |
3.12.0 |
COT.002.103 |
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. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. 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. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
COT.002.102 |
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. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. 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. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
COT.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. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. 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. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
COT.002.100 |
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. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. 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. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
COT.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. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. 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. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
COT.002.098 |
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. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. 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. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
COT.002.096 |
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. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. 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. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
COT.002.095 |
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. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. 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. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
COT.002.094 |
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. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. 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. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/01/2023 |
3.11.0 |
COT.002.073 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Healthcare Acquired Condition Indicator List (VVL).4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Healthcare Acquired Condition Indicator List (VVL).4. Conditional |
| 08/01/2023 |
3.11.0 |
COT.002.072 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Forced Claim Indicator List (VVL)4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Forced Claim Indicator List (VVL)4. Conditional |
| 08/14/2023 |
3.12.0 |
COT.002.070 |
UPDATE |
Coding requirement |
1. Value must be a positive integer2. Value must be between 0:9999 (inclusive)3. Value must not include commas or other non-numeric characters4. Value must be equal to the number of claim lines (e.g. Original Claim Line Number (CE) or Adjustment Claim Line Number (CE) instances) reported in the associated claim record being reported5. Value must be 4 characters or less6. Mandatory |
1. Value must be a positive integer2. Value must be between 0:9999 (inclusive)3. Value must not include commas or other non-numeric characters4. Value must be equal to the number of claim lines (e.g. Original Claim Line Number or Adjustment Claim Line Number instances) reported in the associated claim record being reported5. Value must be 4 characters or less6. Mandatory |
| 06/14/2023 |
3.9.0 |
COT.002.068 |
UPDATE |
Definition |
The field denotes whether the payment amount was determined at the claim header or line/detail level. |
The field denotes whether the payment amount was determined at the claim header or line/detail level.For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines’ associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only.For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header.For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed.For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
| 08/09/2023 |
3.11.0 |
COT.002.066 |
UPDATE |
Definition |
A unique number assigned by the state which represents a distinct comprehensive managed care plan, prepaid health plan, primary care case management program, a program for all-inclusive care for the elderly entity, or other approved plans. |
A unique number assigned by the state which represents a distinct comprehensive managed care plan, prepaid health plan, primary care case management program, a program for all-inclusive care for the elderly entity, or other approved plans.For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report the PLAN-ID-NUMBER for the MCP (MCO, PIHP, or PAHP that has a contract with a state) that is making the payment to the sub-capitated entity or sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 08/01/2023 |
3.11.0 |
COT.002.064 |
UPDATE |
Coding requirement |
1. Value must be in Medicare Combined Deductible Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. Value must be 1 character5. If value equals '1', then Total Medicare Coinsurance amount must not be populated.6. If value equals '0', then Crossover Indicator must equals '0'7. If value equals '1', then Crossover Indicator must equals '1'8. Conditional |
1. Value must be in Medicare Combined Deductible Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If value equals '1', then Total Medicare Coinsurance amount must not be populated.5. If value equals '0', then Crossover Indicator must equals '0'6. If value equals '1', then Crossover Indicator must equals '1'7. Conditional |
| 06/01/2023 |
3.8.0 |
COT.002.063 |
UPDATE |
Coding requirement |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Conditional |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
| 05/31/2023 |
3.8.0 |
COT.002.062 |
UPDATE |
Necessity |
Mandatory |
Conditional |
| 05/31/2023 |
3.8.0 |
COT.002.062 |
UPDATE |
Coding requirement |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Mandatory |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Conditional |
| 08/01/2023 |
3.11.0 |
COT.002.061 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Fixed Payment Indicator List (VVL)4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Fixed Payment Indicator List (VVL)4. Conditional |
| 08/01/2023 |
3.11.0 |
COT.002.057 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Other Insurance Indicator List (VVL)4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Other Insurance Indicator List (VVL)4. Conditional |
| 08/15/2023 |
3.12.0 |
COT.002.054 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than associated Total Billed Amount (CE) - (Total Medicare Coinsurance Amount (CE) + Total Medicare Deductible Amount (CE))4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than associated Total Billed Amount- (Total Medicare Coinsurance Amount + Total Medicare Deductible Amount)4. Conditional |
| 08/09/2023 |
3.11.0 |
COT.002.041 |
UPDATE |
Definition |
The field denotes the claims payment system from which the claim was extracted. |
The field denotes the claims payment system from which the claim was extracted.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = '22' to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis.For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = '23' to indicate that the sub-capitated network provider provided the service directly to the enrollee.For sub-capitation payments, report a SOURCE-LOCATION of '20', indicating the managed care plan is the source of payment. |
| 08/09/2023 |
3.11.0 |
COT.002.037 |
UPDATE |
Definition |
A code to indicate what type of payment is covered in this claim. |
A code to indicate what type of payment is covered in this claim.For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record. |
| 01/05/2023 |
3.2.0 |
COT.002.036 |
UPDATE |
Definition |
The date Medicaid paid this claim or adjustment. |
The date Medicaid paid this claim or adjustment. For Encounter Records (Type of Claim = 3, C, W), the date the managed care organization paid the provider for the claim or adjustment. |
| 09/21/2023 |
3.13.0 |
COT.002.035 |
UPDATE |
Segment key field identifier |
Not Applicable |
5 |
| 08/01/2023 |
3.11.0 |
COT.002.024 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Value must be 1 character5. Conditional6. When value equals '0', is invalid or not populated, the associated 1115A Demonstration Indicator (ELG.018.233) must equal '0', is invalid or not populated |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Conditional5. When value equals '0', is invalid or not populated, the associated 1115A Demonstration Indicator (ELG.018.233) must equal '0', is invalid or not populated |
| 08/28/2023 |
3.12.0 |
COT.002.020 |
UPDATE |
Coding requirement |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional |
Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [‘4’, ‘1’] then value must be populated |
| 09/21/2023 |
3.13.0 |
COT.002.019 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 08/14/2023 |
3.12.0 |
COT.002.018 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
COT.001.014 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
COT.001.012 |
UPDATE |
Coding requirement |
1. Value must be in SSN Indicator List (VVL)2. Value must be 1 character3. Mandatory |
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) |
| 08/14/2023 |
3.12.0 |
COT.001.010 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be equal to or after associated Start of Time Period (CE)6. Mandatory |
1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be equal to or after associated Start of Time Period6. Mandatory |
| 08/14/2023 |
3.12.0 |
COT.001.009 |
UPDATE |
Coding requirement |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be before associated End of Time Period (CE)6. Mandatory |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be before associated End of Time Period6. Mandatory |
| 08/14/2023 |
3.12.0 |
COT.001.008 |
UPDATE |
Coding requirement |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period (CE)6. Mandatory |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period6. Mandatory |
| 08/28/2023 |
3.12.0 |
COT.001.002 |
UPDATE |
Coding requirement |
1. Value must be 10 characters or less2. Value must not include the pipe ("|") symbol3. Mandatory |
1. Value must be 10 characters or less2. Value must be in the Data Dictionary Version List (VVL)3. Mandatory |
| 02/16/2023 |
3.3.0 |
CLT.003.243 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated |
1. Value must be 1 character2. Value must be in [0, 1] |
| 09/21/2023 |
3.13.0 |
CLT.003.233 |
UPDATE |
Segment key field identifier |
Not Applicable |
7 |
| 08/21/2023 |
3.12.0 |
CLT.003.226 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
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 ID |
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) |
| 08/14/2023 |
3.12.0 |
CLT.003.209 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Type of Claim (CE) value equals '3, C, W', then value is mandatory and must be provided4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Type of Claim value equals '3, C, W', then value is mandatory and must be provided4. Conditional |
| 08/09/2023 |
3.11.0 |
CLT.003.208 |
UPDATE |
Definition |
The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. |
The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 08/09/2023 |
3.11.0 |
CLT.003.205 |
UPDATE |
Definition |
The maximum amount displayed at the claim line level as determined by the payer as being "allowable" under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed
care encounters the Allowed Amount is determined by the managed care organization. |
The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed care encounters the Allowed Amount is determined by the managed care organization.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity allowed at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 08/09/2023 |
3.11.0 |
CLT.003.204 |
UPDATE |
Definition |
The total amount billed for the related Revenue Code. Total amount billed includes both covered and non-covered charges (as defined by UB-04 Billing Manual). For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed to the
managed care plan. |
The total amount billed for the related Revenue Code. Total amount billed includes both covered and non-covered charges (as defined by UB-04 Billing Manual). For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed to the managed care plan.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the provider billed the sub-capitated entity at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 09/21/2023 |
3.13.0 |
CLT.003.191 |
UPDATE |
Segment key field identifier |
Not Applicable |
5 |
| 09/21/2023 |
3.13.0 |
CLT.003.190 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 08/28/2023 |
3.12.0 |
CLT.003.189 |
UPDATE |
Coding requirement |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional |
Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [‘4’, ‘1’] then value must be populated |
| 09/21/2023 |
3.13.0 |
CLT.003.188 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 07/13/2023 |
3.10.0 |
CLT.003.187 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less5. When Type of Claim (CLT.002.052) equals 4, D or X (lump sum payment) value must begin with an '&' |
1. Mandatory2. Value must be 20 characters or less3. When Type of Claim (CLT.002.052) equals 4, D or X (lump sum payment) value must begin with an '&' |
| 08/14/2023 |
3.12.0 |
CLT.003.186 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/10/2023 |
3.11.0 |
CLT.002.241 |
UPDATE |
Definition |
The total deductible amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary deductible liability for covered services on the claim. Do not subtract out any payments made toward the
deductible. |
The total deductible amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary deductible liability minus previous beneficiary payments that went toward their deductible. Do not subtract out any payments for the given claim that went toward the deductible. |
| 08/10/2023 |
3.11.0 |
CLT.002.240 |
UPDATE |
Definition |
The total coinsurance amount on a claim that the beneficiary is obligated to pay for covered services. This is the total Medicaid or contract negotiated beneficiary coinsurance liability for covered service on the claim. Do not subtract out any payments made toward the
copayment. |
The total coinsurance amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary coinsurance liability for covered services on the claim. Do not subtract out any payments made toward the coinsurance. |
| 08/15/2023 |
3.12.0 |
CLT.002.174 |
UPDATE |
Coding requirement |
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. Conditional |
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 data file |
| 08/21/2023 |
3.12.0 |
CLT.002.173 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 08/28/2023 |
3.12.0 |
CLT.002.167 |
UPDATE |
Coding requirement |
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. Conditional |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to '2'3. Value must exist in the NPPES NPI data file4. Conditional |
| 08/23/2023 |
3.12.0 |
CLT.002.166 |
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. Must have an associated Third Party Copayment Amount4. Optional |
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. Must have an associated Third Party Copayment Amount4. Situational |
| 08/23/2023 |
3.12.0 |
CLT.002.165 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Optional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Situational |
| 08/23/2023 |
3.12.0 |
CLT.002.164 |
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. Must have an associated Third Party Coinsurance Amount4. Conditional |
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 Amount 4. Conditional |
| 08/23/2023 |
3.12.0 |
CLT.002.163 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Optional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Situational |
| 08/28/2023 |
3.12.0 |
CLT.002.160 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
CLT.002.160 |
UPDATE |
Coding requirement |
1. Value must be in Copay Waived Indicator List (VVL)2. Value must be 1 character3. Optional |
1. Value must be in Copay Waived Indicator List (VVL)2. Value must be 1 character3. Value must be in [0,1] or not populated4. Situational |
| 09/07/2023 |
3.12.0 |
CLT.002.157 |
UPDATE |
Definition |
The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on the claim. Do not include copayment payments made by a third party/s on behalf of the beneficiary. |
The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on the claim. Do not include copayment payments made by a third party/ies on behalf of the beneficiary. |
| 09/07/2023 |
3.12.0 |
CLT.002.155 |
UPDATE |
Definition |
The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on the claim. Do not include copayment payments made by a third party/s on behalf of the beneficiary.. |
The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on the claim. Do not include copayment payments made by a third party/ies on behalf of the beneficiary. |
| 09/07/2023 |
3.12.0 |
CLT.002.153 |
UPDATE |
Definition |
The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their coinsurance for the covered services on the claim. Do not include coinsurance payments made by a third party/s on behalf of the beneficiary. |
The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their coinsurance for the covered services on the claim. Do not include coinsurance payments made by a third party/ies on behalf of the beneficiary. |
| 08/01/2023 |
3.11.0 |
CLT.002.151 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Border State Indicator List (VVL)4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Border State Indicator List (VVL)4. Conditional |
| 09/21/2023 |
3.13.0 |
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. Value must be 1 character5. 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 |
| 07/12/2023 |
3.10.0 |
CLT.002.144 |
UPDATE |
Definition |
The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The first five (5) positions are Julian date following a YYDDD format. The RA is the detailed
explanation of the reason for the payment amount. |
The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The RA is the detailed explanation of the reason for the payment amount. |
| 08/28/2023 |
3.12.0 |
CLT.002.136 |
UPDATE |
Coding requirement |
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. Conditional |
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. Conditional |
| 08/15/2023 |
3.12.0 |
CLT.002.129 |
UPDATE |
Coding requirement |
1. Value must be associated with a populated Waiver Type (CE)2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Conditional |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Conditional |
| 08/28/2023 |
3.12.0 |
CLT.002.127 |
UPDATE |
Coding requirement |
1. Value must be in Health Home Provider Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If there is an associated Health Home Entity Name value, then value must be "1"5. Value must be 1 character6. Conditional |
1. Value must be in Health Home Provider Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If there is an associated Health Home Entity Name value, then value must be "1"5. Conditional |
| 08/14/2023 |
3.12.0 |
CLT.002.121 |
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. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. 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. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
CLT.002.120 |
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. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. 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. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
CLT.002.119 |
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. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. 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. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
CLT.002.118 |
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. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. 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. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
CLT.002.117 |
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. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. 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. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
CLT.002.116 |
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. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. 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. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
CLT.002.115 |
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. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. 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. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
CLT.002.114 |
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. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. 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. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
CLT.002.113 |
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. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. 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. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
CLT.002.112 |
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. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. 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. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/01/2023 |
3.11.0 |
CLT.002.091 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Healthcare Acquired Condition Indicator List (VVL).4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Healthcare Acquired Condition Indicator List (VVL).4. Conditional |
| 08/01/2023 |
3.11.0 |
CLT.002.090 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Forced Claim Indicator List (VVL)4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Forced Claim Indicator List (VVL)4. Conditional |
| 08/14/2023 |
3.12.0 |
CLT.002.087 |
UPDATE |
Coding requirement |
1. Value must be a positive integer2. Value must be between 0:9999 (inclusive)3. Value must not include commas or other non-numeric characters4. Value must be equal to the number of claim lines (e.g. Original Claim Line Number (CE) or Adjustment Claim Line Number (CE) instances) reported in the associated claim record being reported5. Value must be 4 characters or less6. Mandatory |
1. Value must be a positive integer2. Value must be between 0:9999 (inclusive)3. Value must not include commas or other non-numeric characters4. Value must be equal to the number of claim lines (e.g. Original Claim Line Number or Adjustment Claim Line Number instances) reported in the associated claim record being reported5. Value must be 4 characters or less6. Mandatory |
| 06/14/2023 |
3.9.0 |
CLT.002.082 |
UPDATE |
Definition |
The field denotes whether the payment amount was determined at the claim header or line/detail level. |
The field denotes whether the payment amount was determined at the claim header or line/detail level.For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines’ associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only.For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header.For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed.For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
| 08/01/2023 |
3.11.0 |
CLT.002.078 |
UPDATE |
Coding requirement |
1. Value must be in Medicare Combined Deductible Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. Value must be 1 character5. If value equals '1', then Total Medicare Coinsurance amount must not be populated.6. If value equals '0', then Crossover Indicator must equals '0'7. If value equals '1', then Crossover Indicator must equals '1'8. Conditional |
1. Value must be in Medicare Combined Deductible Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If value equals '1', then Total Medicare Coinsurance amount must not be populated.5. If value equals '0', then Crossover Indicator must equals '0'6. If value equals '1', then Crossover Indicator must equals '1'7. Conditional |
| 06/01/2023 |
3.8.0 |
CLT.002.077 |
UPDATE |
Coding requirement |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Conditional |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
| 05/31/2023 |
3.8.0 |
CLT.002.076 |
UPDATE |
Necessity |
Mandatory |
Conditional |
| 05/31/2023 |
3.8.0 |
CLT.002.076 |
UPDATE |
Coding requirement |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Mandatory |
Value must be in Funding Code List (VVL)2. Value must be 1 character3. Conditional |
| 08/01/2023 |
3.11.0 |
CLT.002.075 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Fixed Payment Indicator List (VVL)4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Fixed Payment Indicator List (VVL)4. Conditional |
| 08/01/2023 |
3.11.0 |
CLT.002.071 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Other Insurance Indicator List (VVL)4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Other Insurance Indicator List (VVL)4. Conditional |
| 08/15/2023 |
3.12.0 |
CLT.002.069 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than associated Total Billed Amount (CE) - (Total Medicare Coinsurance Amount (CE) + Total Medicare Deductible Amount (CE))4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than associated Total Billed Amount - (Total Medicare Coinsurance Amount + Total Medicare Deductible Amount)4. Conditional |
| 08/09/2023 |
3.11.0 |
CLT.002.056 |
UPDATE |
Definition |
The field denotes the claims payment system from which the claim was extracted. |
The field denotes the claims payment system from which the claim was extracted.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = '22' to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis.For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = '23' to indicate that the sub-capitated network provider provided the service directly to the enrollee.For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = “23” to indicate that the sub-capitated network provider provided the service directly to the enrollee. |
| 08/09/2023 |
3.11.0 |
CLT.002.052 |
UPDATE |
Definition |
A code to indicate what type of payment is covered in this claim. |
A code to indicate what type of payment is covered in this claim.For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record. |
| 01/05/2023 |
3.2.0 |
CLT.002.051 |
UPDATE |
Definition |
The date Medicaid paid this claim or adjustment. |
The date Medicaid paid this claim or adjustment. For Encounter Records (Type of Claim = 3, C, W), the date the managed care organization paid the provider for the claim or adjustment. |
| 09/21/2023 |
3.13.0 |
CLT.002.050 |
UPDATE |
Segment key field identifier |
Not Applicable |
5 |
| 08/14/2023 |
3.12.0 |
CLT.002.046 |
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. Value must be less than or equal to associated Adjudication Date (CE) value.4. Value must be greater than or equal to associated Admission Date (CE) value.5. Value must be greater than or equal to associated eligible Date of Birth (CE) value.6. Value must be less than or equal to associated eligible Date of Death (CE) value.7. Conditional8. When populated, Discharge Hour (CLT.002.047) must be populated |
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. Value must be less than or equal to associated Adjudication Date value.4. Value must be greater than or equal to associated Admission Date value.5. Value must be greater than or equal to associated eligible Date of Birth value.6. Value must be less than or equal to associated eligible Date of Death value.7. Conditional8. When populated, Discharge Hour (CLT.002.047) must be populated |
| 08/14/2023 |
3.12.0 |
CLT.002.044 |
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. Value must be less than or equal to associated Discharge Date (CE) value in the claim header.4. Value must be greater than or equal to associated eligible Date of Birth (CE) value.5. Value must be less than or equal to associated eligible Date of Death (CE) value.6. Mandatory7. When associated Type of Claim (CLT.002.052) is not '2','B' or 'V' (capitated payment) value must be before Adjudication Date (CLT.002.050)8. When associated Type of Claim (CLT.002.052) is not '2','B' or 'V' (capitated payment) and Type of Service (CLT.003.211) is not '119, '120', '121', 122' value must be before Adjudication Date (CLT.003.233) |
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. Value must be less than or equal to associated Discharge Date value in the claim header.4. Value must be greater than or equal to associated eligible Date of Birth value.5. Value must be less than or equal to associated eligible Date of Death value.6. Mandatory7. When associated Type of Claim (CLT.002.052) is not '2','B' or 'V' (capitated payment) value must be before Adjudication Date (CLT.002.050)8. When associated Type of Claim (CLT.002.052) is not '2','B' or 'V' (capitated payment) and Type of Service (CLT.003.211) is not '119, '120', '121', 122' value must be before Adjudication Date (CLT.003.233) |
| 08/15/2023 |
3.12.0 |
CLT.002.028 |
UPDATE |
Coding requirement |
1. Value must be in Diagnosis Code Flag List(VVL)2. Value must be 1 character |
1. Value must be in Diagnosis Code Flag List(VVL)2. Value must be 1 character3. Conditional |
| 08/01/2023 |
3.11.0 |
CLT.002.024 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Value must be 1 character5. Conditional6. When value equals '0', is invalid or not populated, the associated 1115A Demonstration Indicator (ELG.018.233) must equal '0', is invalid or not populated |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Conditional5. When value equals '0', is invalid or not populated, the associated 1115A Demonstration Indicator (ELG.018.233) must equal '0', is invalid or not populated |
| 08/28/2023 |
3.12.0 |
CLT.002.020 |
UPDATE |
Coding requirement |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [‘4’, ‘1’] then value must be populated |
| 09/21/2023 |
3.13.0 |
CLT.002.019 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 08/14/2023 |
3.12.0 |
CLT.002.018 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
CLT.001.014 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
CLT.001.012 |
UPDATE |
Coding requirement |
1. Value must be in SSN Indicator List (VVL)2. Value must be 1 character3. Mandatory |
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) |
| 08/14/2023 |
3.12.0 |
CLT.001.010 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be equal to or after associated Start of Time Period (CE)6. Mandatory |
1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be equal to or after associated Start of Time Period6. Mandatory |
| 08/14/2023 |
3.12.0 |
CLT.001.009 |
UPDATE |
Coding requirement |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be before associated End of Time Period (CE)6. Mandatory |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be before associated End of Time Period6. Mandatory |
| 08/14/2023 |
3.12.0 |
CLT.001.008 |
UPDATE |
Coding requirement |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period (CE)6. Mandatory |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period6. Mandatory |
| 08/28/2023 |
3.12.0 |
CLT.001.002 |
UPDATE |
Coding requirement |
1. Value must be 10 characters or less2. Value must not include the pipe ("|") symbol3. Mandatory |
Value must be 10 characters or less2. Value must be in the Data Dictionary Version List (VVL)3. Mandatory |
| 02/16/2023 |
3.3.0 |
CIP.003.296 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated |
1. Value must be 1 character2. Value must be in [0, 1] |
| 09/21/2023 |
3.13.0 |
CIP.003.286 |
UPDATE |
Segment key field identifier |
Not Applicable |
7 |
| 08/21/2023 |
3.12.0 |
CIP.003.273 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 08/16/2023 |
3.12.0 |
CIP.003.269 |
UPDATE |
Coding requirement |
1. Value must be in CMS 64 Category for Federal Reimbursement List (VVL)2. Value must be 2 characters3. (Federal Funding under Title XXI) if value equals '02', then the eligible's CHIP Code (ELG.003.054) must be in ['2', '3']4. (Federal Funding under Title XIX) if value equals '01' then the eligible's CHIP Code (ELG.003.054) must be '1'5. Conditional6. If Type of Claim is in ['1','2','5','A','B','E','U','V','Y'] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported.7. If Type of Claim is in ['4','D'] and the Service Tracking Payment Amount on the relevant record is populated, then value must be reported. |
Value must be in CMS 64 Category for Federal Reimbursement List (VVL)2. Value must be 2 characters3. (Federal Funding under Title XXI) if value equals '02', then the eligible's CHIP Code (ELG.003.054) must be in ['2', '3']4. (Federal Funding under Title XIX) if value equals '01' then the eligible's CHIP Code (ELG.003.054) must be '1'5. Conditional6. If Type of Claim is in ['1','2','5','A','B','E','U','V','Y'] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported.7. If Type of Claim is in ['4','D'] and the Service Tracking Payment Amount on the relevant record is populated, then value must be reported.8. When Type of Claim is in [‘1’, ‘A’], value must be populated |
| 09/21/2023 |
3.13.0 |
CIP.003.265 |
UPDATE |
Coding requirement |
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. Conditional |
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 |
| 09/21/2023 |
3.13.0 |
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 ID |
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) |
| 09/01/2023 |
3.12.0 |
CIP.003.255 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Type of Claim (CE) value equals '3, C, W', then value is mandatory and must be provided4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Type of Claim value equals '3, C, W', then value is mandatory and must be provided4. Conditional |
| 08/09/2023 |
3.11.0 |
CIP.003.254 |
UPDATE |
Definition |
The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. |
The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 08/09/2023 |
3.11.0 |
CIP.003.252 |
UPDATE |
Definition |
The maximum amount displayed at the claim line level as determined by the payer as being "allowable" under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed
care encounters the Allowed Amount is determined by the managed care organization. |
The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed care encounters the Allowed Amount is determined by the managed care organization.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity allowed at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 08/09/2023 |
3.11.0 |
CIP.003.251 |
UPDATE |
Definition |
The total amount billed for the related Revenue Code. Total amount billed includes both covered and non-covered charges (as defined by UB-04 Billing Manual). For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed to the
managed care plan. |
The total amount billed for the related Revenue Code. Total amount billed includes both covered and non-covered charges (as defined by UB-04 Billing Manual). For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed to the managed care plan.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the provider billed the sub-capitated entity at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 09/21/2023 |
3.13.0 |
CIP.003.238 |
UPDATE |
Segment key field identifier |
Not Applicable |
5 |
| 09/21/2023 |
3.13.0 |
CIP.003.237 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 08/28/2023 |
3.12.0 |
CIP.003.236 |
UPDATE |
Coding requirement |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional |
Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [‘4’, ‘1’] then value must be populated |
| 09/21/2023 |
3.13.0 |
CIP.003.235 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 07/13/2023 |
3.10.0 |
CIP.003.234 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less5. When Type of Claim (CIP.002.100) = 4, D or X (lump sum payment) value must begin with an '&' |
1. Mandatory2. Value must be 20 characters or less3. When Type of Claim (CIP.002.100) = 4, D or X (lump sum payment) value must begin with an '&' |
| 08/14/2023 |
3.12.0 |
CIP.003.233 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/10/2023 |
3.11.0 |
CIP.002.294 |
UPDATE |
Definition |
The total deductible amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary deductible liability for covered services on the claim. Do not subtract out any payments made toward the
deductible. |
The total deductible amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary deductible liability minus previous beneficiary payments that went toward their deductible. Do not subtract out any payments for the given claim that went toward the deductible. |
| 08/10/2023 |
3.11.0 |
CIP.002.293 |
UPDATE |
Definition |
The total coinsurance amount on a claim that the beneficiary is obligated to pay for covered services. This is the total Medicaid or contract negotiated beneficiary coinsurance liability for covered service on the claim. Do not subtract out any payments made toward the
copayment. |
The total coinsurance amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary coinsurance liability for covered services on the claim. Do not subtract out any payments made toward the coinsurance. |
| 08/21/2023 |
3.12.0 |
CIP.002.229 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 08/28/2023 |
3.12.0 |
CIP.002.221 |
UPDATE |
Coding requirement |
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. Conditional |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to '2' 3. Value must exist in the NPPES NPI data file4. Conditional |
| 08/28/2023 |
3.12.0 |
CIP.002.220 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional4. When Type of Claim is in ['4', 'D', 'X'], value must not be populated |
| 08/23/2023 |
3.12.0 |
CIP.002.219 |
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. Must have an associated Third Party Copayment Amount4. Optional |
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. Must have an associated Third Party Copayment Amount4. Situational |
| 08/23/2023 |
3.12.0 |
CIP.002.218 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Optional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Situational |
| 08/23/2023 |
3.12.0 |
CIP.002.217 |
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. Must have an associated Third Party Coinsurance Amount4. Conditional |
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 Amount 4. Conditional |
| 08/23/2023 |
3.12.0 |
CIP.002.216 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Optional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Situational |
| 08/28/2023 |
3.12.0 |
CIP.002.213 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
CIP.002.213 |
UPDATE |
Coding requirement |
1. Value must be in Copay Waived Indicator List (VVL)2. Value must be 1 character3. Optional |
1. Value must be in Copay Waived Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. Situational |
| 09/07/2023 |
3.12.0 |
CIP.002.210 |
UPDATE |
Definition |
The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their deductible for the covered services on the claim. Do not include deductible payments made by a third party/s on behalf of the beneficiary. |
The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their deductible for the covered services on the claim. Do not include deductible payments made by a third party/ies on behalf of the beneficiary. |
| 09/07/2023 |
3.12.0 |
CIP.002.208 |
UPDATE |
Definition |
The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on the claim. Do not include copayment payments made by a third party/s on behalf of the beneficiary. |
The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on the claim. Do not include copayment payments made by a third party/ies on behalf of the beneficiary. |
| 09/07/2023 |
3.12.0 |
CIP.002.206 |
UPDATE |
Definition |
The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their coinsurance for the covered services on the claim. Do not include coinsurance payments made by a third party/s on behalf of the beneficiary. |
The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their coinsurance for the covered services on the claim. Do not include coinsurance payments made by a third party/ies on behalf of the beneficiary. |
| 08/01/2023 |
3.11.0 |
CIP.002.204 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Border State Indicator List (VVL)4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Border State Indicator List (VVL)4. Conditional |
| 09/21/2023 |
3.13.0 |
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. Value must be 1 character5. 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 |
| 07/12/2023 |
3.10.0 |
CIP.002.202 |
UPDATE |
Definition |
The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The first five (5) positions are Julian date following a YYDDD format. The RA is the detailed
explanation of the reason for the payment amount. |
The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The RA is the detailed explanation of the reason for the payment amount. |
| 07/12/2023 |
3.10.0 |
CIP.002.194 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must not be populated, if Outlier Code (CIP.002.197) equals '00' or '09'4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be populated, if Outlier Code (CIP.002.197) equals '00' or '09'4. Conditional |
| 08/28/2023 |
3.12.0 |
CIP.002.190 |
UPDATE |
Coding requirement |
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. Conditional |
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. Conditional |
| 08/15/2023 |
3.12.0 |
CIP.002.184 |
UPDATE |
Coding requirement |
1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Conditional3. Value must have an associated Provider Identifier Type equal to '2' |
1. Value must be 10 digits2. Conditional3. Value must have an associated Provider Identifier Type equal to '2'4. Value must exist in the NPPES NPI File |
| 08/15/2023 |
3.12.0 |
CIP.002.178 |
UPDATE |
Coding requirement |
1. Value must be associated with a populated Waiver Type (CE)2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Conditional |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Conditional |
| 08/28/2023 |
3.12.0 |
CIP.002.176 |
UPDATE |
Coding requirement |
1. Value must be in Health Home Provider Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If there is an associated Health Home Entity Name value, then value must be "1"5. Value must be 1 character6. Conditional |
1. Value must be in Health Home Provider Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If there is an associated Health Home Entity Name value, then value must be "1"5. Conditional |
| 08/14/2023 |
3.12.0 |
CIP.002.169 |
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. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. 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. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
CIP.002.168 |
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. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. 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. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
CIP.002.166 |
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. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. 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. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
CIP.002.165 |
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. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. 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. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
CIP.002.164 |
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. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. 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. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
CIP.002.163 |
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. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. 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. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
CIP.002.162 |
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. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. 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. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
CIP.002.161 |
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. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. 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. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
CIP.002.160 |
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. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. 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. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/01/2023 |
3.11.0 |
CIP.002.139 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Healthcare Acquired Condition Indicator List (VVL).4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Healthcare Acquired Condition Indicator List (VVL).4. Conditional |
| 08/01/2023 |
3.11.0 |
CIP.002.138 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Forced Claim Indicator List (VVL)4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Forced Claim Indicator List (VVL)4. Conditional |
| 08/14/2023 |
3.12.0 |
CIP.002.137 |
UPDATE |
Coding requirement |
1. Value must be a positive integer2. Value must be between 0:9999 (inclusive)3. Value must not include commas or other non-numeric characters4. Value must be equal to the number of claim lines (e.g. Original Claim Line Number (CE) or Adjustment Claim Line Number (CE) instances) reported in the associated claim record being reported5. Value must be 4 characters or less6. Mandatory |
1. Value must be a positive integer2. Value must be between 0:9999 (inclusive)3. Value must not include commas or other non-numeric characters4. Value must be equal to the number of claim lines (e.g. Original Claim Line Number or Adjustment Claim Line Number instances) reported in the associated claim record being reported5. Value must be 4 characters or less6. Mandatory |
| 06/14/2023 |
3.9.0 |
CIP.002.132 |
UPDATE |
Definition |
The field denotes whether the payment amount was determined at the claim header or line/detail level. |
The field denotes whether the payment amount was determined at the claim header or line/detail level.For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines’ associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only.For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header.For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed.For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
| 08/01/2023 |
3.11.0 |
CIP.002.128 |
UPDATE |
Coding requirement |
1. Value must be in Medicare Combined Deductible Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. Value must be 1 character5. If value equals '1', then Total Medicare Coinsurance amount must not be populated.6. If value equals '0', then Crossover Indicator must equals '0'7. If value equals '1', then Crossover Indicator must equals '1'8. Conditional |
1. Value must be in Medicare Combined Deductible Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If value equals '1', then Total Medicare Coinsurance amount must not be populated.5. If value equals '0', then Crossover Indicator must equals '0'6. If value equals '1', then Crossover Indicator must equals '1'7. Conditional |
| 06/01/2023 |
3.8.0 |
CIP.002.127 |
UPDATE |
Coding requirement |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Conditional |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
| 05/31/2023 |
3.8.0 |
CIP.002.126 |
UPDATE |
Necessity |
Mandatory |
Conditional |
| 05/31/2023 |
3.8.0 |
CIP.002.126 |
UPDATE |
Coding requirement |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Mandatory |
Value must be in Funding Code List (VVL)2. Value must be 1 character3. Conditional |
| 08/01/2023 |
3.11.0 |
CIP.002.125 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Fixed Payment Indicator List (VVL)4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Fixed Payment Indicator List (VVL)4. Conditional |
| 08/01/2023 |
3.11.0 |
CIP.002.121 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Other Insurance Indicator List (VVL)4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Other Insurance Indicator List (VVL)4. Conditional |
| 08/15/2023 |
3.12.0 |
CIP.002.118 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than associated Total Billed Amount (CE) - (Total Medicare Coinsurance Amount (CE) + Total Medicare Deductible Amount (CE))4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than associated Total Billed Amount - (Total Medicare Coinsurance Amount + Total Medicare Deductible Amount)4. Conditional |
| 08/09/2023 |
3.11.0 |
CIP.002.104 |
UPDATE |
Definition |
The field denotes the claims payment system from which the claim was extracted. |
The field denotes the claims payment system from which the claim was extracted.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = '22' to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis.For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = '23' to indicate that the sub-capitated network provider provided the service directly to the enrollee.For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = “23” to indicate that the sub-capitated network provider provided the service directly to the enrollee. |
| 08/09/2023 |
3.11.0 |
CIP.002.100 |
UPDATE |
Definition |
A code to indicate what type of payment is covered in this claim. |
A code to indicate what type of payment is covered in this claim.For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record. |
| 01/05/2023 |
3.2.0 |
CIP.002.099 |
UPDATE |
Definition |
The date Medicaid paid this claim or adjustment. |
The date Medicaid paid this claim or adjustment. For Encounter Records (Type of Claim = 3, C, W), the date the managed care organization paid the provider for the claim or adjustment. |
| 09/21/2023 |
3.13.0 |
CIP.002.098 |
UPDATE |
Segment key field identifier |
Not Applicable |
5 |
| 09/21/2023 |
3.13.0 |
CIP.002.069 |
UPDATE |
Medicaid valid value info |
Values are generated by combining two types of information: Position 1-2, State/Group generating DRG: If state specific system, fill with two digit US postal code representation for state.If CMS Grouper, fill with 'HG'.If any other system, fill with 'XX'.Position 3-4, fill with the number that represents the DRG version used (01-98).For example, 'HG15' would represent CMS Grouper version 15. If version is unknown, fill with '99'. |
|
| 09/21/2023 |
3.13.0 |
CIP.002.068 |
UPDATE |
Medicaid valid value info |
If the first two characters of the diagnosis related group indicator is 'HG' which indicates a CMS DRG Group code was assigned, then the value for the diagnosis related group must be from the following list of valid values. |
|
| 08/15/2023 |
3.12.0 |
CIP.002.031 |
UPDATE |
Coding requirement |
1. Value must be in Diagnosis Code Flag List(VVL)2. Value must be 1 character |
1. Value must be in Diagnosis Code Flag List(VVL)2. Value must be 1 character3. Conditional |
| 08/01/2023 |
3.11.0 |
CIP.002.025 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Value must be 1 character5. Conditional6. When value equals '0', is invalid or not populated, then the associated 1115A Demonstration Indicator (ELG.018.233) must equal '0', is invalid or not populated |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Conditional5. When value equals '0', is invalid or not populated, then the associated 1115A Demonstration Indicator (ELG.018.233) must equal '0', is invalid or not populated |
| 08/28/2023 |
3.12.0 |
CIP.002.020 |
UPDATE |
Coding requirement |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional |
Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [‘4’, ‘1’] then value must be populated |
| 09/21/2023 |
3.13.0 |
CIP.002.019 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 08/14/2023 |
3.12.0 |
CIP.002.018 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
CIP.001.014 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
CIP.001.012 |
UPDATE |
Coding requirement |
1. Value must be in SSN Indicator List (VVL)2. Value must be 1 character3. Mandatory |
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) |
| 08/14/2023 |
3.12.0 |
CIP.001.010 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be equal to or after associated Start of Time Period (CE)6. Mandatory |
1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be equal to or after associated Start of Time Period6. Mandatory |
| 08/14/2023 |
3.12.0 |
CIP.001.009 |
UPDATE |
Coding requirement |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be before associated End of Time Period (CE)6. Mandatory |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be before associated End of Time Period6. Mandatory |
| 08/14/2023 |
3.12.0 |
CIP.001.008 |
UPDATE |
Coding requirement |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period (CE)6. Mandatory |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period6. Mandatory |
| 08/28/2023 |
3.12.0 |
CIP.001.002 |
UPDATE |
Coding requirement |
1. Value must be 10 characters or less2. Value must not include the pipe ("|") symbol3. Mandatory |
1. Value must be 10 characters or less2. Value must be in the Data Dictionary Version List (VVL)3. Mandatory |
| 12/22/2022 |
3.1.0 |
Data Elements |
UPDATE |
Description |
Specifications for all the data elements including valid values and related rules and measures. |
Specifications for all the data elements including valid values, related rules, and measures. |
| 06/02/2023 |
3.8.0 |
EL-1-031-38 |
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 OtherOf the MSIS IDs that meet the criteria from STEP 2, further restrict them by the following criteria:1. RACE-CODE equals "018" 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. |
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 OtherOf the MSIS IDs that meet the criteria from STEP 2, further restrict them by the following criteria:1. RACE equals "018" 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. |
| 12/09/2022 |
3.0.6 |
EL-1-031-38 |
ADD |
N/A |
|
Created |
| 06/02/2023 |
3.8.0 |
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-CODE = (“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. |
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. |
| 12/09/2022 |
3.0.6 |
EL-1-030-37 |
ADD |
N/A |
|
Created |
| 06/02/2023 |
3.8.0 |
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-CODE = (“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. |
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. |
| 12/09/2022 |
3.0.6 |
EL-1-029-36 |
ADD |
N/A |
|
Created |
| 06/02/2023 |
3.8.0 |
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-CODE 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. |
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. |
| 12/09/2022 |
3.0.6 |
EL-1-028-35 |
ADD |
N/A |
|
Created |
| 06/02/2023 |
3.8.0 |
EL-1-027-34 |
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: 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 Black or African AmericanOf the MSIS IDs that meet the criteria from STEP 2, further restrict them by the following criteria:1. RACE-CODE equals "002" 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. |
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 Black or African AmericanOf the MSIS IDs that meet the criteria from STEP 2, further restrict them by the following criteria:1. RACE equals "002" 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. |
| 12/09/2022 |
3.0.6 |
EL-1-027-34 |
ADD |
N/A |
|
Created |
| 06/02/2023 |
3.8.0 |
EL-1-026-33 |
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: 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 WhiteOf the MSIS IDs that meet the criteria from STEP 2, further restrict them by the following criteria:1. RACE-CODE equals "001" 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. |
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 WhiteOf the MSIS IDs that meet the criteria from STEP 2, further restrict them by the following criteria:1. RACE equals "001" 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. |
| 12/09/2022 |
3.0.6 |
EL-1-026-33 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
MCR-65-012-12 |
UPDATE |
Priority |
N/A |
High |
| 09/06/2023 |
3.12.0 |
MCR-65-012-12 |
UPDATE |
Category |
N/A |
Program participation |
| 09/06/2023 |
3.12.0 |
MCR-65-012-12 |
UPDATE |
For ta comprehensive |
No |
TA- Inferential |
| 09/06/2023 |
3.12.0 |
MCR-65-012-12 |
UPDATE |
For ta inferential |
No |
Yes |
| 09/06/2023 |
3.12.0 |
MCR-65-012-12 |
UPDATE |
Ta min |
|
0 |
| 09/06/2023 |
3.12.0 |
MCR-65-012-12 |
UPDATE |
Ta max |
|
0.1 |
| 09/06/2023 |
3.12.0 |
MCR-65-012-12 |
UPDATE |
Threshold minimum |
TBD |
0 |
| 09/06/2023 |
3.12.0 |
MCR-65-012-12 |
UPDATE |
Threshold maximum |
TBD |
0.1 |
| 12/09/2022 |
3.0.6 |
MCR-65-012-12 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
MCR-65-011-11 |
UPDATE |
Priority |
N/A |
High |
| 09/06/2023 |
3.12.0 |
MCR-65-011-11 |
UPDATE |
Category |
N/A |
Program participation |
| 09/06/2023 |
3.12.0 |
MCR-65-011-11 |
UPDATE |
For ta comprehensive |
No |
TA- Inferential |
| 09/06/2023 |
3.12.0 |
MCR-65-011-11 |
UPDATE |
For ta inferential |
No |
Yes |
| 09/06/2023 |
3.12.0 |
MCR-65-011-11 |
UPDATE |
Ta min |
|
0 |
| 09/06/2023 |
3.12.0 |
MCR-65-011-11 |
UPDATE |
Ta max |
|
0.1 |
| 09/06/2023 |
3.12.0 |
MCR-65-011-11 |
UPDATE |
Threshold minimum |
TBD |
0 |
| 09/06/2023 |
3.12.0 |
MCR-65-011-11 |
UPDATE |
Threshold maximum |
TBD |
0.1 |
| 12/09/2022 |
3.0.6 |
MCR-65-011-11 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
MCR-65-010-10 |
UPDATE |
Priority |
N/A |
High |
| 09/06/2023 |
3.12.0 |
MCR-65-010-10 |
UPDATE |
Category |
N/A |
Program participation |
| 09/06/2023 |
3.12.0 |
MCR-65-010-10 |
UPDATE |
For ta comprehensive |
No |
TA- Inferential |
| 09/06/2023 |
3.12.0 |
MCR-65-010-10 |
UPDATE |
For ta inferential |
No |
Yes |
| 09/06/2023 |
3.12.0 |
MCR-65-010-10 |
UPDATE |
Ta min |
|
0 |
| 09/06/2023 |
3.12.0 |
MCR-65-010-10 |
UPDATE |
Ta max |
|
0.1 |
| 09/06/2023 |
3.12.0 |
MCR-65-010-10 |
UPDATE |
Threshold minimum |
TBD |
0 |
| 09/06/2023 |
3.12.0 |
MCR-65-010-10 |
UPDATE |
Threshold maximum |
TBD |
0.1 |
| 12/09/2022 |
3.0.6 |
MCR-65-010-10 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
MCR-65-009-9 |
UPDATE |
Priority |
N/A |
High |
| 09/06/2023 |
3.12.0 |
MCR-65-009-9 |
UPDATE |
Category |
N/A |
Program participation |
| 09/06/2023 |
3.12.0 |
MCR-65-009-9 |
UPDATE |
For ta comprehensive |
No |
TA- Inferential |
| 09/06/2023 |
3.12.0 |
MCR-65-009-9 |
UPDATE |
For ta inferential |
No |
Yes |
| 09/06/2023 |
3.12.0 |
MCR-65-009-9 |
UPDATE |
Ta min |
|
0 |
| 09/06/2023 |
3.12.0 |
MCR-65-009-9 |
UPDATE |
Ta max |
|
0.1 |
| 09/06/2023 |
3.12.0 |
MCR-65-009-9 |
UPDATE |
Threshold minimum |
TBD |
0 |
| 09/06/2023 |
3.12.0 |
MCR-65-009-9 |
UPDATE |
Threshold maximum |
TBD |
0.1 |
| 12/09/2022 |
3.0.6 |
MCR-65-009-9 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
MCR-65-008-8 |
UPDATE |
Priority |
N/A |
High |
| 09/06/2023 |
3.12.0 |
MCR-65-008-8 |
UPDATE |
Category |
N/A |
Program participation |
| 09/06/2023 |
3.12.0 |
MCR-65-008-8 |
UPDATE |
For ta comprehensive |
No |
TA- Inferential |
| 09/06/2023 |
3.12.0 |
MCR-65-008-8 |
UPDATE |
For ta inferential |
No |
Yes |
| 09/06/2023 |
3.12.0 |
MCR-65-008-8 |
UPDATE |
Ta min |
|
0 |
| 09/06/2023 |
3.12.0 |
MCR-65-008-8 |
UPDATE |
Ta max |
|
0.1 |
| 09/06/2023 |
3.12.0 |
MCR-65-008-8 |
UPDATE |
Threshold minimum |
TBD |
0 |
| 09/06/2023 |
3.12.0 |
MCR-65-008-8 |
UPDATE |
Threshold maximum |
TBD |
0.1 |
| 12/09/2022 |
3.0.6 |
MCR-65-008-8 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
MCR-65-007-7 |
UPDATE |
Priority |
N/A |
High |
| 09/06/2023 |
3.12.0 |
MCR-65-007-7 |
UPDATE |
Category |
N/A |
Program participation |
| 09/06/2023 |
3.12.0 |
MCR-65-007-7 |
UPDATE |
For ta comprehensive |
No |
TA- Inferential |
| 09/06/2023 |
3.12.0 |
MCR-65-007-7 |
UPDATE |
For ta inferential |
No |
Yes |
| 09/06/2023 |
3.12.0 |
MCR-65-007-7 |
UPDATE |
Ta min |
|
0 |
| 09/06/2023 |
3.12.0 |
MCR-65-007-7 |
UPDATE |
Ta max |
|
0.1 |
| 09/06/2023 |
3.12.0 |
MCR-65-007-7 |
UPDATE |
Threshold minimum |
TBD |
0 |
| 09/06/2023 |
3.12.0 |
MCR-65-007-7 |
UPDATE |
Threshold maximum |
TBD |
0.1 |
| 12/09/2022 |
3.0.6 |
MCR-65-007-7 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
MCR-65-006-6 |
UPDATE |
Priority |
N/A |
High |
| 09/06/2023 |
3.12.0 |
MCR-65-006-6 |
UPDATE |
Category |
N/A |
Program participation |
| 09/06/2023 |
3.12.0 |
MCR-65-006-6 |
UPDATE |
For ta comprehensive |
No |
TA- Inferential |
| 09/06/2023 |
3.12.0 |
MCR-65-006-6 |
UPDATE |
For ta inferential |
No |
Yes |
| 09/06/2023 |
3.12.0 |
MCR-65-006-6 |
UPDATE |
Ta min |
|
0 |
| 09/06/2023 |
3.12.0 |
MCR-65-006-6 |
UPDATE |
Ta max |
|
0.1 |
| 09/06/2023 |
3.12.0 |
MCR-65-006-6 |
UPDATE |
Threshold minimum |
TBD |
0 |
| 09/06/2023 |
3.12.0 |
MCR-65-006-6 |
UPDATE |
Threshold maximum |
TBD |
0.1 |
| 12/09/2022 |
3.0.6 |
MCR-65-006-6 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
MCR-65-005-5 |
UPDATE |
Priority |
N/A |
High |
| 09/06/2023 |
3.12.0 |
MCR-65-005-5 |
UPDATE |
Category |
N/A |
Program participation |
| 09/06/2023 |
3.12.0 |
MCR-65-005-5 |
UPDATE |
For ta comprehensive |
No |
TA- Inferential |
| 09/06/2023 |
3.12.0 |
MCR-65-005-5 |
UPDATE |
For ta inferential |
No |
Yes |
| 09/06/2023 |
3.12.0 |
MCR-65-005-5 |
UPDATE |
Ta min |
|
0 |
| 09/06/2023 |
3.12.0 |
MCR-65-005-5 |
UPDATE |
Ta max |
|
0.1 |
| 09/06/2023 |
3.12.0 |
MCR-65-005-5 |
UPDATE |
Threshold minimum |
TBD |
0 |
| 09/06/2023 |
3.12.0 |
MCR-65-005-5 |
UPDATE |
Threshold maximum |
TBD |
0.1 |
| 12/09/2022 |
3.0.6 |
MCR-65-005-5 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
MCR-65-004-4 |
UPDATE |
Priority |
N/A |
High |
| 09/06/2023 |
3.12.0 |
MCR-65-004-4 |
UPDATE |
Category |
N/A |
Program participation |
| 09/06/2023 |
3.12.0 |
MCR-65-004-4 |
UPDATE |
For ta comprehensive |
No |
TA- Inferential |
| 09/06/2023 |
3.12.0 |
MCR-65-004-4 |
UPDATE |
For ta inferential |
No |
Yes |
| 09/06/2023 |
3.12.0 |
MCR-65-004-4 |
UPDATE |
Ta min |
|
0 |
| 09/06/2023 |
3.12.0 |
MCR-65-004-4 |
UPDATE |
Ta max |
|
0.1 |
| 09/06/2023 |
3.12.0 |
MCR-65-004-4 |
UPDATE |
Threshold minimum |
TBD |
0 |
| 09/06/2023 |
3.12.0 |
MCR-65-004-4 |
UPDATE |
Threshold maximum |
TBD |
0.1 |
| 12/09/2022 |
3.0.6 |
MCR-65-004-4 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
MCR-65-003-3 |
UPDATE |
Priority |
N/A |
High |
| 09/06/2023 |
3.12.0 |
MCR-65-003-3 |
UPDATE |
Category |
N/A |
Program participation |
| 09/06/2023 |
3.12.0 |
MCR-65-003-3 |
UPDATE |
For ta comprehensive |
No |
TA- Inferential |
| 09/06/2023 |
3.12.0 |
MCR-65-003-3 |
UPDATE |
For ta inferential |
No |
Yes |
| 09/06/2023 |
3.12.0 |
MCR-65-003-3 |
UPDATE |
Ta min |
|
0 |
| 09/06/2023 |
3.12.0 |
MCR-65-003-3 |
UPDATE |
Ta max |
|
0.1 |
| 09/06/2023 |
3.12.0 |
MCR-65-003-3 |
UPDATE |
Threshold minimum |
TBD |
0 |
| 09/06/2023 |
3.12.0 |
MCR-65-003-3 |
UPDATE |
Threshold maximum |
TBD |
0.1 |
| 12/09/2022 |
3.0.6 |
MCR-65-003-3 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
MCR-65-002-2 |
UPDATE |
Priority |
N/A |
High |
| 09/06/2023 |
3.12.0 |
MCR-65-002-2 |
UPDATE |
Category |
N/A |
Program participation |
| 09/06/2023 |
3.12.0 |
MCR-65-002-2 |
UPDATE |
For ta comprehensive |
No |
TA- Inferential |
| 09/06/2023 |
3.12.0 |
MCR-65-002-2 |
UPDATE |
For ta inferential |
No |
Yes |
| 09/06/2023 |
3.12.0 |
MCR-65-002-2 |
UPDATE |
Ta min |
|
0 |
| 09/06/2023 |
3.12.0 |
MCR-65-002-2 |
UPDATE |
Ta max |
|
0.1 |
| 09/06/2023 |
3.12.0 |
MCR-65-002-2 |
UPDATE |
Threshold minimum |
TBD |
0 |
| 09/06/2023 |
3.12.0 |
MCR-65-002-2 |
UPDATE |
Threshold maximum |
TBD |
0.1 |
| 12/09/2022 |
3.0.6 |
MCR-65-002-2 |
ADD |
N/A |
|
Created |
| 09/06/2023 |
3.12.0 |
MCR-65-001-1 |
UPDATE |
Priority |
N/A |
High |
| 09/06/2023 |
3.12.0 |
MCR-65-001-1 |
UPDATE |
Category |
N/A |
Program participation |
| 09/06/2023 |
3.12.0 |
MCR-65-001-1 |
UPDATE |
For ta comprehensive |
No |
TA- Inferential |
| 09/06/2023 |
3.12.0 |
MCR-65-001-1 |
UPDATE |
For ta inferential |
No |
Yes |
| 09/06/2023 |
3.12.0 |
MCR-65-001-1 |
UPDATE |
Ta min |
|
0 |
| 09/06/2023 |
3.12.0 |
MCR-65-001-1 |
UPDATE |
Ta max |
|
0.1 |
| 09/06/2023 |
3.12.0 |
MCR-65-001-1 |
UPDATE |
Threshold minimum |
TBD |
0 |
| 09/06/2023 |
3.12.0 |
MCR-65-001-1 |
UPDATE |
Threshold maximum |
TBD |
0.1 |
| 12/09/2022 |
3.0.6 |
MCR-65-001-1 |
ADD |
N/A |
|
Created |
| 01/27/2023 |
3.2.0 |
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 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 |
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 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 |
| 01/27/2023 |
3.2.0 |
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 month3. 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 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 |
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 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 |
| 01/27/2023 |
3.2.0 |
PRV-6-002-2 |
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 Lookup Designation is "Facility or Group" or 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:1a. PROV-IDENTIFIER-TYPE and PROVIDER-CLASSIFICATION-CODE match values in Provider Classification lookup tableAND1b. Provider Classification Lookup Designation = “Facility” or "Group"OR2. PROV-IDENTIFIER-TYPE and PROVIDER-CLASSIFICATION-CODE do not equal to values in Provider Classification lookup tableOR3. PROV-IDENTIFIER-TYPE is missingOR4. PROVIDER-CLASSIFICATION-CODE is 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 |
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 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 Lookup Designation is "Facility or Group" or 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:1a. PROV-IDENTIFIER-TYPE and PROVIDER-CLASSIFICATION-CODE match values in Provider Classification lookup tableAND1b. Provider Classification Lookup Designation = “Facility” or "Group"OR2. PROV-IDENTIFIER-TYPE and PROVIDER-CLASSIFICATION-CODE do not equal to values in Provider Classification lookup tableOR3. PROV-IDENTIFIER-TYPE is missingOR4. PROVIDER-CLASSIFICATION-CODE is 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 |
| 01/27/2023 |
3.2.0 |
PRV-6-001-1 |
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 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 Lookup Designation is "Individual" or 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:1a. PROV-IDENTIFIER-TYPE and PROVIDER-CLASSIFICATION-CODE match values in Provider Classification lookup tableAND1b. Provider Classification Lookup Designation = “Individual”OR2. PROV-IDENTIFIER-TYPE and PROVIDER-CLASSIFICATION-CODE do not equal to values in Provider Classification lookup tableOR3. PROV-IDENTIFIER-TYPE is missingOR4. PROVIDER-CLASSIFICATION-CODE is 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 |
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 Lookup Designation is "Individual" or 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:1a. PROV-IDENTIFIER-TYPE and PROVIDER-CLASSIFICATION-CODE match values in Provider Classification lookup tableAND1b. Provider Classification Lookup Designation = “Individual”OR2. PROV-IDENTIFIER-TYPE and PROVIDER-CLASSIFICATION-CODE do not equal to values in Provider Classification lookup tableOR3. PROV-IDENTIFIER-TYPE is missingOR4. PROVIDER-CLASSIFICATION-CODE is 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 |
| 04/21/2023 |
3.6.0 |
EL-19-001-1 |
UPDATE |
Specification |
STEP 1: Enrolled any 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 >= first day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Enrolled any day of prior DQ report monthDefine the prior 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 prior DQ report month 2. ENROLLMENT-END-DATE >= first day of the prior DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 3: Enrolled in prior month but not current monthKeep all MSIS IDs from STEP 2 that are NOT in STEP 1STEP 4: Eligibility determinants any day of prior 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 = 12. ELIGIBILITY-DETERMINANT-EFF-DATE <= last day of the prior DQ report month3. ELIGIBILITY-DETERMINANT-END-DATE >= first day of the prior DQ report month OR missing*Note: If multiple segments meet the criteria for one MSIS ID, keep latest one (sort by max end date, max effective date, min record byte offset)STEP 5: Valid, known eligibility change reasonOf the MSIS IDs that meet the criteria from STEP 4, further refine the population by keeping records with: 1. ELIGIBILITY-CHANGE-REASON = (“01”,“02”,“03”,“04”,“05”, “06”,”07”,“08”,“09”,“10”,“11”,“12”, “13”,“14”,“15”,“16”,“17”, “18”,“19”, or “20”)STEP 6: Missing, invalid, unknown, or other eligibility change reasonKeep all MSIS IDs from STEP 3 that are NOT in STEP 5STEP 7: Calculate percentageDivide the unique count of MSIS IDs from STEP 6 by the unique count of MSIS IDs from STEP 3 |
STEP 1: Enrolled any 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 >= first day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Enrolled any day of prior DQ report monthDefine the prior 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 prior DQ report month 2. ENROLLMENT-END-DATE >= first day of the prior DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 3: Enrolled in prior month but not current monthKeep all MSIS IDs from STEP 2 that are NOT in STEP 1STEP 4: Eligibility determinants any day of prior 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 = 12. ELIGIBILITY-DETERMINANT-EFF-DATE <= last day of the prior DQ report month3. ELIGIBILITY-DETERMINANT-END-DATE >= first day of the prior DQ report month OR missing*Note: If multiple segments meet the criteria for one MSIS ID, keep latest one (sort by max end date, max effective date, min record byte offset)STEP 5: Valid, known eligibility change reasonOf the MSIS IDs that meet the criteria from STEP 4, further refine the population by keeping records with: 1. ELIGIBILITY-CHANGE-REASON = (“01”,“02”,“04”, “06”,”07”,“08”,“09”,“10”,“11”,“12”, “13”,“14”,“15”,“16”,“17”, “18”,“19”, “20”, “23”, “24”, “25”, “26”, “27”, “28”, “29”, “30”, or “31”)STEP 6: Missing, invalid, unknown, or other eligibility change reasonKeep all MSIS IDs from STEP 3 that are NOT in STEP 5STEP 7: Calculate percentageDivide the unique count of MSIS IDs from STEP 6 by the unique count of MSIS IDs from STEP 3 |
| 12/22/2022 |
3.1.0 |
Data Quality Measures |
UPDATE |
Version text |
|
3.4.0 |
| 03/24/2023 |
3.5.0 |
CRX - CLAIM PRESCRIPTION |
UPDATE |
Title |
CRX - CLAIM PERSCRIPTION |
CRX - CLAIM PRESCRIPTION |
| 03/24/2023 |
3.5.0 |
CRX - CLAIM PRESCRIPTION |
UPDATE |
File name |
CRX - CLAIM PERSCRIPTION |
CRX - CLAIM PRESCRIPTION |
| 04/21/2023 |
3.6.0 |
RULE-7645 |
UPDATE |
File type |
CRX |
Multiple Files |
| 04/21/2023 |
3.6.0 |
RULE-7644 |
UPDATE |
File type |
COT |
Multiple Files |
| 04/21/2023 |
3.6.0 |
RULE-7643 |
UPDATE |
File type |
CLT |
Multiple Files |
| 04/21/2023 |
3.6.0 |
RULE-7642 |
UPDATE |
File type |
CIP |
Multiple Files |
| 09/06/2023 |
3.12.0 |
RULE-7559 |
UPDATE |
Priority |
High |
N/A |
| 09/06/2023 |
3.12.0 |
RULE-7559 |
UPDATE |
Category |
Beneficiary demographics |
N/A |
| 09/06/2023 |
3.12.0 |
RULE-7559 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 09/06/2023 |
3.12.0 |
RULE-7559 |
UPDATE |
For ta inferential |
Yes |
No |
| 09/06/2023 |
3.12.0 |
RULE-7559 |
UPDATE |
Ta min |
0 |
|
| 09/06/2023 |
3.12.0 |
RULE-7559 |
UPDATE |
Ta max |
0.001 |
|
| 06/02/2023 |
3.8.0 |
EL-1-014-32 |
UPDATE |
Priority |
N/A |
Medium |
| 06/02/2023 |
3.8.0 |
EL-1-014-32 |
UPDATE |
Category |
N/A |
Beneficiary eligibility |
| 06/02/2023 |
3.8.0 |
EL-1-014-32 |
UPDATE |
For ta comprehensive |
No |
TA- Inferential |
| 06/02/2023 |
3.8.0 |
EL-1-014-32 |
UPDATE |
For ta inferential |
No |
Yes |
| 06/02/2023 |
3.8.0 |
EL-1-014-32 |
UPDATE |
Ta min |
|
0 |
| 06/02/2023 |
3.8.0 |
EL-1-014-32 |
UPDATE |
Ta max |
|
0.5 |
| 06/02/2023 |
3.8.0 |
EL-1-014-32 |
UPDATE |
Threshold minimum |
TBD |
0 |
| 06/02/2023 |
3.8.0 |
EL-1-014-32 |
UPDATE |
Threshold maximum |
TBD |
0.5 |
| 04/21/2023 |
3.6.0 |
MCR-64-004_1-8 |
UPDATE |
Specification |
STEP 1: Active non-duplicate RX records during DQ report monthDefine the RX records universe at the header level by importing both headers and lines that satisfy the following criteria:For Headers: 1. Reporting Period for the filename = DQ report month2. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing3. CLAIM-DENIED-INDICATOR is not equal to "0" or is missing4. TYPE-OF-CLAIM is not equal to "Z" or is missing5. CLAIM-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing6. No Header Duplicates: Duplicates are dropped at the header-level, if the following four data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND.For Lines:1. Reporting Period from the filename = DQ report month2. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing3. No Line Duplicates: Duplicates are dropped at the line level if the following data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, LINE-NUM-ORIG, LINE-NUM-ADJ, and LINE-ADJSTMT-IND.4. Lines merge to a header using ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND=LINE-ADJSTMT-IND.STEP 2: Medicaid and S-CHIP Encounter: Non-void, Crossover, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "3" or "C"2. CROSSOVER-IND = "1"3. ADJUSTMENT-IND not equal to "1" STEP 3: No Medicare AmountsOf the claims that meet the criteria from STEP 2, further restrict them by the following criteria: 1. MEDICARE-PAID-AMT = 0 or is missing on all lines2. TOT-MEDICARE-COINS-AMT = 0 or is missing3. TOT-MEDICARE-DEDUCTIBLE-AMT = 0 or is missingSTEP 4: Calculate percentageDivide the count of claim headers from STEP 3 by the count of claim headers from STEP 2 |
STEP 1: Active non-duplicate RX records during DQ report monthDefine the RX records universe at the header level by importing both headers and lines that satisfy the following criteria:For Headers: 1. Reporting Period for the filename = DQ report month2. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing3. CLAIM-DENIED-INDICATOR is not equal to "0" or is missing4. TYPE-OF-CLAIM is not equal to "Z" or is missing5. CLAIM-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing6. No Header Duplicates: Duplicates are dropped at the header-level, if the following four data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND.For Lines:1. Reporting Period from the filename = DQ report month2. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing3. No Line Duplicates: Duplicates are dropped at the line level if the following data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, LINE-NUM-ORIG, LINE-NUM-ADJ, and LINE-ADJSTMT-IND.4. Lines merge to a header using ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND=LINE-ADJSTMT-IND.STEP 2: Medicaid and S-CHIP Encounter: Non-void, Crossover, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "3" or "C"2. CROSSOVER-IND = "1"3. ADJUSTMENT-IND not equal to "1" STEP 3: Exclude sub-capitation encountersOf 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: No Medicare AmountsOf the claims that meet the criteria from STEP 3, further restrict them by the following criteria: 1. MEDICARE-PAID-AMT = 0 or is missing on all lines2. TOT-MEDICARE-COINS-AMT = 0 or is missing3. TOT-MEDICARE-DEDUCTIBLE-AMT = 0 or is missingSTEP 5: Calculate percentageDivide the count of claim headers from STEP 4 by the count of claim headers from STEP 3. |
| 04/21/2023 |
3.6.0 |
MCR-64-003_1-7 |
UPDATE |
Specification |
STEP 1: Active non-duplicate OT records during DQ report monthDefine the OT records universe at the header level by importing both headers and lines that satisfy the following criteria:For Headers: 1. Reporting Period for the filename = DQ report month2. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing3. CLAIM-DENIED-INDICATOR is not equal to "0" or is missing4. TYPE-OF-CLAIM is not equal to "Z" or is missing5. CLAIM-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing6. No Header Duplicates: Duplicates are dropped at the header-level, if the following four data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND.For Lines:1. Reporting Period from the filename = DQ report month2. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing3. No Line Duplicates: Duplicates are dropped at the line level if the following data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, LINE-NUM-ORIG, LINE-NUM-ADJ, and LINE-ADJSTMT-IND.4. Lines merge to a header using ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND=LINE-ADJSTMT-IND.STEP 2: Medicaid and S-CHIP Encounter: Non-void, Crossover, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "3" or "C"2. CROSSOVER-IND = "1"3. ADJUSTMENT-IND not equal to "1" STEP 3: No Medicare AmountsOf the claims that meet the criteria from STEP 2, further restrict them by the following criteria: 1. MEDICARE-PAID-AMT = 0 or is missing on all lines2. TOT-MEDICARE-COINS-AMT = 0 or is missing3. TOT-MEDICARE-DEDUCTIBLE-AMT = 0 or is missingSTEP 4: Calculate percentageDivide the count of claim headers from STEP 3 by the count of claim headers from STEP 2 |
STEP 1: Active non-duplicate OT records during DQ report monthDefine the OT records universe at the header level by importing both headers and lines that satisfy the following criteria:For Headers: 1. Reporting Period for the filename = DQ report month2. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing3. CLAIM-DENIED-INDICATOR is not equal to "0" or is missing4. TYPE-OF-CLAIM is not equal to "Z" or is missing5. CLAIM-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing6. No Header Duplicates: Duplicates are dropped at the header-level, if the following four data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND.For Lines:1. Reporting Period from the filename = DQ report month2. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing3. No Line Duplicates: Duplicates are dropped at the line level if the following data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, LINE-NUM-ORIG, LINE-NUM-ADJ, and LINE-ADJSTMT-IND.4. Lines merge to a header using ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND=LINE-ADJSTMT-IND.STEP 2: Medicaid and S-CHIP Encounter: Non-void, Crossover, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "3" or "C"2. CROSSOVER-IND = "1"3. ADJUSTMENT-IND not equal to "1" STEP 3: Exclude sub-capitation encountersOf 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: No Medicare AmountsOf the claims that meet the criteria from STEP 3, further restrict them by the following criteria: 1. MEDICARE-PAID-AMT = 0 or is missing on all lines2. TOT-MEDICARE-COINS-AMT = 0 or is missing3. TOT-MEDICARE-DEDUCTIBLE-AMT = 0 or is missingSTEP 5: Calculate percentageDivide the count of claim headers from STEP 4 by the count of claim headers from STEP 3. |
| 04/21/2023 |
3.6.0 |
MCR-64-002_1-6 |
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: Medicaid and S-CHIP Encounter: Non-void, Crossover, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "3" or "C"2. CROSSOVER-IND = "1"3. ADJUSTMENT-IND not equal to "1" STEP 3: No Medicare Amounts Of the claims that meet the criteria from STEP 2, further restrict them by the following criteria: 1. MEDICARE-PAID-AMT = 0 or is missing2. TOT-MEDICARE-COINS-AMT = 0 or is missing3. TOT-MEDICARE-DEDUCTIBLE-AMT = 0 or is missingSTEP 4: Calculate percentageDivide the count of claim headers from STEP 3 by the count of claim headers from STEP 2 |
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: Medicaid and S-CHIP Encounter: Non-void, Crossover, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "3" or "C"2. CROSSOVER-IND = "1"3. ADJUSTMENT-IND not equal to "1" STEP 3: Exclude sub-capitation encountersOf 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: No Medicare Amounts Of the claims that meet the criteria from STEP 3, further restrict them by the following criteria: 1. MEDICARE-PAID-AMT = 0 or is missing2. TOT-MEDICARE-COINS-AMT = 0 or is missing3. TOT-MEDICARE-DEDUCTIBLE-AMT = 0 or is missingSTEP 5: Calculate percentageDivide the count of claim headers from STEP 4 by the count of claim headers from STEP 3. |
| 04/21/2023 |
3.6.0 |
MCR-64-001_1-5 |
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: Medicaid and S-CHIP Encounter: Non-void, Crossover, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "3" or "C"2. CROSSOVER-IND = "1"3. ADJUSTMENT-IND not equal to "1" STEP 3: No Medicare AmountsOf the claims that meet the criteria from STEP 2, further restrict them by the following criteria: 1. MEDICARE-PAID-AMT = 0 or is missing2. TOT-MEDICARE-COINS-AMT = 0 or is missing3. TOT-MEDICARE-DEDUCTIBLE-AMT = 0 or is missingSTEP 4: Calculate percentageDivide the count of claim headers from STEP 3 by the count of claim headers from STEP 2 |
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: Medicaid and S-CHIP Encounter: Non-void, Crossover, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "3" or "C"2. CROSSOVER-IND = "1"3. ADJUSTMENT-IND not equal to "1" STEP 3: Exclude sub-capitation encountersOf 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: No Medicare AmountsOf the claims that meet the criteria from STEP 3, further restrict them by the following criteria: 1. MEDICARE-PAID-AMT = 0 or is missing2. TOT-MEDICARE-COINS-AMT = 0 or is missing3. TOT-MEDICARE-DEDUCTIBLE-AMT = 0 or is missingSTEP 5: Calculate percentageDivide the count of claim headers from STEP 4 by the count of claim headers from STEP 3. |
| 04/21/2023 |
3.6.0 |
FFS-54-004_1-8 |
UPDATE |
Priority |
High |
N/A |
| 04/21/2023 |
3.6.0 |
FFS-54-004_1-8 |
UPDATE |
Category |
Expenditures |
N/A |
| 04/21/2023 |
3.6.0 |
FFS-54-004_1-8 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 04/21/2023 |
3.6.0 |
FFS-54-004_1-8 |
UPDATE |
For ta inferential |
Yes |
No |
| 04/21/2023 |
3.6.0 |
FFS-54-004_1-8 |
UPDATE |
Ta min |
0 |
|
| 04/21/2023 |
3.6.0 |
FFS-54-004_1-8 |
UPDATE |
Ta max |
0.1 |
|
| 04/21/2023 |
3.6.0 |
FFS-54-004_1-8 |
UPDATE |
Annotation |
Calculate the percentage of Medicaid and S-CHIP FFS: non-void, crossover, paid RX claims where Medicare paid amount, total Medicare coinsurance amount, and total Medicare deductible amount are equal to 0 or are missing |
N/A |
| 04/21/2023 |
3.6.0 |
FFS-54-004_1-8 |
UPDATE |
Specification |
STEP 1: Active non-duplicate RX records during DQ report monthDefine the RX records universe at the header level by importing both headers and lines that satisfy the following criteria:For Headers:1. Reporting Period for the filename = DQ report month2. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing3. CLAIM-DENIED-INDICATOR is not equal to "0" or is missing4. TYPE-OF-CLAIM is not equal to "Z" or is missing5. CLAIM-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing6. No Header Duplicates: Duplicates are dropped at the header-level, if the following four data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND.For Lines:1. Reporting Period from the filename = DQ report month2. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing3. No Line Duplicates: Duplicates are dropped at the line level if the following data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, LINE-NUM-ORIG, LINE-NUM-ADJ, and LINE-ADJSTMT-IND.4. Lines merge to a header using ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND=LINE-ADJSTMT-IND.STEP 2: Medicaid and S-CHIP FFS: Non-void, Crossover, 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. CROSSOVER-IND = "1"3. ADJUSTMENT-IND not equal to "1" STEP 3: No Medicare AmountsOf the claims that meet the criteria from STEP 2, further restrict them by the following criteria: 1. MEDICARE-PAID-AMT = 0 or is missing on all lines2. TOT-MEDICARE-COINS-AMT = 0 or is missing3. TOT-MEDICARE-DEDUCTIBLE-AMT = 0 or is missingSTEP 4: Calculate percentageDivide the count of claim headers from STEP 3 by the count of claim headers from STEP 2 |
N/A |
| 04/21/2023 |
3.6.0 |
FFS-54-003_1-7 |
UPDATE |
Priority |
High |
N/A |
| 04/21/2023 |
3.6.0 |
FFS-54-003_1-7 |
UPDATE |
Category |
Expenditures |
N/A |
| 04/21/2023 |
3.6.0 |
FFS-54-003_1-7 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 04/21/2023 |
3.6.0 |
FFS-54-003_1-7 |
UPDATE |
For ta inferential |
Yes |
No |
| 04/21/2023 |
3.6.0 |
FFS-54-003_1-7 |
UPDATE |
Ta min |
0 |
|
| 04/21/2023 |
3.6.0 |
FFS-54-003_1-7 |
UPDATE |
Ta max |
0.1 |
|
| 04/21/2023 |
3.6.0 |
FFS-54-003_1-7 |
UPDATE |
Annotation |
Calculate the percentage of Medicaid and S-CHIP FFS: non-void, crossover, paid OT claims where Medicare paid amount, total Medicare coinsurance amount, and total Medicare deductible amount are equal to 0 or are missing |
N/A |
| 04/21/2023 |
3.6.0 |
FFS-54-003_1-7 |
UPDATE |
Specification |
STEP 1: Active non-duplicate OT records during DQ report monthDefine the OT records universe at the header level by importing both headers and lines that satisfy the following criteria:For Headers: 1. Reporting Period for the filename = DQ report month2. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing3. CLAIM-DENIED-INDICATOR is not equal to "0" or is missing4. TYPE-OF-CLAIM is not equal to "Z" or is missing5. CLAIM-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing6. No Header Duplicates: Duplicates are dropped at the header-level, if the following four data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND.For Lines:1. Reporting Period from the filename = DQ report month2. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing3. No Line Duplicates: Duplicates are dropped at the line level if the following data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, LINE-NUM-ORIG, LINE-NUM-ADJ, and LINE-ADJSTMT-IND.4. Lines merge to a header using ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND=LINE-ADJSTMT-IND.STEP 2: Medicaid and S-CHIP FFS: Non-void, Crossover, 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. CROSSOVER-IND = "1"3. ADJUSTMENT-IND not equal to "1" STEP 3: No Medicare AmountsOf the claims that meet the criteria from STEP 2, further restrict them by the following criteria: 1. MEDICARE-PAID-AMT = 0 or is missing on all lines2. TOT-MEDICARE-COINS-AMT = 0 or is missing3. TOT-MEDICARE-DEDUCTIBLE-AMT = 0 or is missingSTEP 4: Calculate percentageDivide the count of claim headers from STEP 3 by the count of claim headers from STEP 2 |
N/A |
| 04/21/2023 |
3.6.0 |
FFS-54-002_1-6 |
UPDATE |
Priority |
High |
N/A |
| 04/21/2023 |
3.6.0 |
FFS-54-002_1-6 |
UPDATE |
Category |
Expenditures |
N/A |
| 04/21/2023 |
3.6.0 |
FFS-54-002_1-6 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 04/21/2023 |
3.6.0 |
FFS-54-002_1-6 |
UPDATE |
For ta inferential |
Yes |
No |
| 04/21/2023 |
3.6.0 |
FFS-54-002_1-6 |
UPDATE |
Ta min |
0 |
|
| 04/21/2023 |
3.6.0 |
FFS-54-002_1-6 |
UPDATE |
Ta max |
0.1 |
|
| 04/21/2023 |
3.6.0 |
FFS-54-002_1-6 |
UPDATE |
Annotation |
Calculate the percentage of Medicaid and S-CHIP FFS: non-void, crossover, paid LT claims where Medicare paid amount, total Medicare coinsurance amount, and total Medicare deductible amount are equal to 0 or are missing |
N/A |
| 04/21/2023 |
3.6.0 |
FFS-54-002_1-6 |
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: Medicaid and S-CHIP FFS: Non-void, Crossover, 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. CROSSOVER-IND = "1"3. ADJUSTMENT-IND not equal to "1" STEP 3: No Medicare AmountsOf the claims that meet the criteria from STEP 2, further restrict them by the following criteria: 1. MEDICARE-PAID-AMT = 0 or is missing2. TOT-MEDICARE-COINS-AMT = 0 or is missing3. TOT-MEDICARE-DEDUCTIBLE-AMT = 0 or is missingSTEP 4: Calculate percentageDivide the count of claim headers from STEP 3 by the count of claim headers from STEP 2 |
N/A |
| 04/21/2023 |
3.6.0 |
FFS-54-001_1-5 |
UPDATE |
Priority |
High |
N/A |
| 04/21/2023 |
3.6.0 |
FFS-54-001_1-5 |
UPDATE |
Category |
Expenditures |
N/A |
| 04/21/2023 |
3.6.0 |
FFS-54-001_1-5 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 04/21/2023 |
3.6.0 |
FFS-54-001_1-5 |
UPDATE |
For ta inferential |
Yes |
No |
| 04/21/2023 |
3.6.0 |
FFS-54-001_1-5 |
UPDATE |
Ta min |
0 |
|
| 04/21/2023 |
3.6.0 |
FFS-54-001_1-5 |
UPDATE |
Ta max |
0.1 |
|
| 04/21/2023 |
3.6.0 |
FFS-54-001_1-5 |
UPDATE |
Annotation |
Calculate the percentage of Medicaid and S-CHIP FFS: non-void, crossover, paid IP claims where Medicare paid amount, total Medicare coinsurance amount, and total Medicare deductible amount are equal to 0 or are missing |
N/A |
| 04/21/2023 |
3.6.0 |
FFS-54-001_1-5 |
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: Medicaid and S-CHIP FFS: Non-void, Crossover, 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. CROSSOVER-IND = "1"3. ADJUSTMENT-IND not equal to "1" STEP 3: No Medicare AmountsOf the claims that meet the criteria from STEP 2, further restrict them by the following criteria: 1. MEDICARE-PAID-AMT = 0 or is missing2. TOT-MEDICARE-COINS-AMT = 0 or is missing3. TOT-MEDICARE-DEDUCTIBLE-AMT = 0 or is missingSTEP 4: Calculate percentageDivide the count of claim headers from STEP 3 by the count of claim headers from STEP 2 |
N/A |
| 03/10/2023 |
3.4.0 |
EL-3-019_1-34 |
UPDATE |
Annotation |
Calculate the percentage of MSIS IDs with an ELIGIBILITY-GROUP value of "73", "74", or "75" for states NOT expected to report these values according to MBES enrollment data |
Calculate the percentage of MSIS IDs with an ELIGIBILITY-GROUP value of "73", "74", or "75" for states NOT expected to report these values according to public MBES enrollment data on Medicaid.gov |
| 03/10/2023 |
3.4.0 |
EL-3-019_1-34 |
UPDATE |
Specification |
STEP 1: Measure applies to submitting state1a. If submitting state is NOT expected to report ELIGIBILITY-GROUP value "73", "74", or "75" because there are NO enrollees in any "Not Newly Eligible" category in the MBES enrollment data, proceed to STEP 2.ELSE1b. If submitting state is expected to report ELIGIBILITY-GROUP value "73", "74", or "75" because there are enrollees in any "Not Newly Eligible" category in the MBES enrollment data, the final measure statistic will be displayed as "N/A".STEP 2: 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 3: Eligibility determinants on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 2, 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 4: MSIS IDs with eligibility group 73, 74, or 75Of the MSIS IDs that meet the criteria from STEP 3, count the number of unique MSIS IDs where ELIGIBILITY-GROUP = "73", "74", or "75"STEP 5: Calculate percentageDivide the count from STEP 4 by the count from STEP 2 |
STEP 1: Measure applies to submitting state1a. If submitting state is NOT expected to report ELIGIBILITY-GROUP value "73", "74", or "75" because there are NO enrollees in any "Not Newly Eligible" category in the MBES enrollment data, proceed to STEP 2.ELSE1b. If submitting state is expected to report ELIGIBILITY-GROUP value "73", "74", or "75" because there are enrollees in any "Not Newly Eligible" category in the public MBES enrollment data on Medicaid.gov, the final measure statistic will be displayed as "N/A".STEP 2: 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 3: Eligibility determinants on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 2, 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 4: MSIS IDs with eligibility group 73, 74, or 75Of the MSIS IDs that meet the criteria from STEP 3, count the number of unique MSIS IDs where ELIGIBILITY-GROUP = "73", "74", or "75"STEP 5: Calculate percentageDivide the count from STEP 4 by the count from STEP 2 |
| 03/10/2023 |
3.4.0 |
EL-3-016_1-33 |
UPDATE |
Annotation |
Calculate the percentage of MSIS IDs with an ELIGIBILITY-GROUP value of "73", "74", or "75" for states expected to report these values according to MBES enrollment data |
Calculate the percentage of MSIS IDs with an ELIGIBILITY-GROUP value of "73", "74", or "75" for states expected to report these values according to public MBES enrollment data on Medicaid.gov |
| 03/10/2023 |
3.4.0 |
EL-3-016_1-33 |
UPDATE |
Specification |
STEP 1: Measure applies to submitting state1a. If submitting state is expected to report ELIGIBILITY-GROUP value "73", "74", or "75" because there are enrollees in any "Not Newly Eligible" category in the MBES enrollment data, proceed to STEP 2ELSE1b. If submitting state is NOT expected to report ELIGIBILITY-GROUP value "73", "74", or "75" because there are NO enrollees in any “Not Newly Eligible” category in the MBES enrollment data, the final measure statistic will be displayed as "N/A"STEP 2: 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 3: Eligibility determinants on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 2, 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 4: MSIS IDs with eligibility group 73, 74, or 75Of the MSIS IDs that meet the criteria from STEP 3, count the number of unique MSIS IDs where ELIGIBILITY-GROUP = "73", "74", or "75"STEP 5: Calculate percentageDivide the count from STEP 4 by the count from STEP 2 |
STEP 1: Measure applies to submitting state1a. If submitting state is expected to report ELIGIBILITY-GROUP value "73", "74", or "75" because there are enrollees in any "Not Newly Eligible" category in the MBES enrollment data, proceed to STEP 2ELSE1b. If submitting state is NOT expected to report ELIGIBILITY-GROUP value "73", "74", or "75" because there are NO enrollees in any “Not Newly Eligible” category in the public MBES enrollment data on Medicaid.gov, the final measure statistic will be displayed as "N/A"STEP 2: 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 3: Eligibility determinants on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 2, 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 4: MSIS IDs with eligibility group 73, 74, or 75Of the MSIS IDs that meet the criteria from STEP 3, count the number of unique MSIS IDs where ELIGIBILITY-GROUP = "73", "74", or "75"STEP 5: Calculate percentageDivide the count from STEP 4 by the count from STEP 2 |
| 09/06/2023 |
3.12.0 |
RULE-7438 |
UPDATE |
Adjustment type |
Non-void |
All Adjustment Types |
| 09/06/2023 |
3.12.0 |
RULE-7437 |
UPDATE |
Adjustment type |
Non-void |
All Adjustment Types |
| 09/06/2023 |
3.12.0 |
RULE-7436 |
UPDATE |
Adjustment type |
Non-void |
All Adjustment Types |
| 09/06/2023 |
3.12.0 |
RULE-7435 |
UPDATE |
Adjustment type |
Non-void |
All Adjustment Types |
| 12/09/2022 |
3.0.6 |
RULE-2382 |
UPDATE |
Priority |
High |
Critical |
| 12/09/2022 |
3.0.6 |
RULE-2382 |
UPDATE |
Category |
Managed care file |
File integrity |
| 12/09/2022 |
3.0.6 |
RULE-2382 |
UPDATE |
Ta max |
0.01 |
0.05 |
| 12/09/2022 |
3.0.6 |
RULE-2382 |
UPDATE |
Threshold maximum |
0.01 |
0.05 |
| 03/10/2023 |
3.4.0 |
EL-1-025-31 |
UPDATE |
Ta max |
0.01 |
0.001 |
| 03/10/2023 |
3.4.0 |
EL-1-025-31 |
UPDATE |
Threshold maximum |
0.01 |
0.001 |
| 03/10/2023 |
3.4.0 |
EL-6-036-36 |
UPDATE |
Priority |
N/A |
High |
| 03/10/2023 |
3.4.0 |
EL-6-036-36 |
UPDATE |
For ta comprehensive |
No |
TA- Inferential |
| 03/10/2023 |
3.4.0 |
EL-6-036-36 |
UPDATE |
For ta inferential |
No |
Yes |
| 03/10/2023 |
3.4.0 |
EL-6-036-36 |
UPDATE |
Ta min |
|
0 |
| 03/10/2023 |
3.4.0 |
EL-6-036-36 |
UPDATE |
Ta max |
|
0.02 |
| 03/10/2023 |
3.4.0 |
EL-6-036-36 |
UPDATE |
Threshold minimum |
TBD |
0 |
| 03/10/2023 |
3.4.0 |
EL-6-036-36 |
UPDATE |
Threshold maximum |
TBD |
0.02 |
| 01/27/2023 |
3.2.0 |
EL-6-032-35 |
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: 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: Money Follows the Person participationOf the MSIS IDs that meet the criteria from STEP 2, further refine the population by keeping MSIS IDs where:1. RESTRICTED-BENEFITS-CODE = “D”STEP 4: MFP enrollment on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 3, join to segment MFP-INFORMATION-ELG00010 by keeping records that satisfy the following criteria:1. MFP-ENROLLMENT-EFF-DATE <= last day of the DQ report month AND is not missing2. MFP-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingSTEP 5: No MFP EnrollmentSubtract the count of unique MSIS IDs from STEP 3 by the count of unique MSIS IDs from STEP 4STEP 6: Calculate percentageDivide the count of unique MSIS IDs from STEP 54 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: 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: Money Follows the Person participationOf the MSIS IDs that meet the criteria from STEP 2, further refine the population by keeping MSIS IDs where:1. RESTRICTED-BENEFITS-CODE = “D”STEP 4: MFP enrollment on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 3, join to segment MFP-INFORMATION-ELG00010 by keeping records that satisfy the following criteria:1. MFP-ENROLLMENT-EFF-DATE <= last day of the DQ report month AND is not missing2. MFP-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingSTEP 5: No MFP EnrollmentSubtract the count of unique MSIS IDs from STEP 3 by the count of unique MSIS IDs from STEP 4STEP 6: Calculate percentageDivide the count of unique MSIS IDs from STEP 5 by the count of unique MSIS IDs from STEP 3 |
| 03/10/2023 |
3.4.0 |
MIS-90-001-1 |
UPDATE |
Priority |
N/A |
High |
| 03/10/2023 |
3.4.0 |
MIS-90-001-1 |
UPDATE |
For ta comprehensive |
No |
TA- Inferential |
| 03/10/2023 |
3.4.0 |
MIS-90-001-1 |
UPDATE |
For ta inferential |
No |
Yes |
| 03/10/2023 |
3.4.0 |
MIS-90-001-1 |
UPDATE |
Ta min |
|
0 |
| 03/10/2023 |
3.4.0 |
MIS-90-001-1 |
UPDATE |
Ta max |
|
0.02 |
| 03/10/2023 |
3.4.0 |
MIS-90-001-1 |
UPDATE |
Threshold minimum |
TBD |
0 |
| 03/10/2023 |
3.4.0 |
MIS-90-001-1 |
UPDATE |
Threshold maximum |
TBD |
0.02 |
| 03/10/2023 |
3.4.0 |
MIS-90-001-1 |
UPDATE |
Annotation |
N/A |
Character |
| 03/10/2023 |
3.4.0 |
MIS-90-001-1 |
UPDATE |
Specification |
N/A |
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: S-CHIP Capitation Payment: 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 = "B"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 |
| 03/10/2023 |
3.4.0 |
MIS-88-001-1 |
UPDATE |
Priority |
N/A |
High |
| 03/10/2023 |
3.4.0 |
MIS-88-001-1 |
UPDATE |
For ta comprehensive |
No |
TA- Inferential |
| 03/10/2023 |
3.4.0 |
MIS-88-001-1 |
UPDATE |
For ta inferential |
No |
Yes |
| 03/10/2023 |
3.4.0 |
MIS-88-001-1 |
UPDATE |
Ta min |
|
0 |
| 03/10/2023 |
3.4.0 |
MIS-88-001-1 |
UPDATE |
Ta max |
|
0.02 |
| 03/10/2023 |
3.4.0 |
MIS-88-001-1 |
UPDATE |
Threshold minimum |
TBD |
0 |
| 03/10/2023 |
3.4.0 |
MIS-88-001-1 |
UPDATE |
Threshold maximum |
TBD |
0.02 |
| 03/10/2023 |
3.4.0 |
MIS-88-001-1 |
UPDATE |
Annotation |
N/A |
Character |
| 03/10/2023 |
3.4.0 |
MIS-88-001-1 |
UPDATE |
Specification |
N/A |
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 Capitation Payment: 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 = "2"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 |
| 04/21/2023 |
3.6.0 |
MIS-86-020-20 |
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: 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 |
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-86-002-2 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) |
| 04/21/2023 |
3.6.0 |
MIS-86-018-18 |
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: 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 |
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-86-002-2 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) |
| 04/21/2023 |
3.6.0 |
MIS-86-015-15 |
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: 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 |
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-86-002-2 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) |
| 04/21/2023 |
3.6.0 |
MIS-86-014-14 |
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: 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 |
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-86-002-2 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) |
| 04/21/2023 |
3.6.0 |
MIS-86-003-3 |
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 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: 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 |
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-86-002-2 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) |
| 04/21/2023 |
3.6.0 |
MIS-86-002-2 |
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: 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 |
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-86-002-2 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) |
| 04/21/2023 |
3.6.0 |
MIS-85-026-26 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-85-025-25 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-85-022-22 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-85-021-21 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-85-019-19 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-85-016-16 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-85-014-14 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-85-011-11 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-85-010-10 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-85-009-9 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-85-007-7 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-85-006-6 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-84-030-30 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-84-028-28 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-84-026-26 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-84-025-25 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-84-024-24 |
UPDATE |
Priority |
N/A |
Medium |
| 04/21/2023 |
3.6.0 |
MIS-84-024-24 |
UPDATE |
Category |
N/A |
Utilization |
| 04/21/2023 |
3.6.0 |
MIS-84-024-24 |
UPDATE |
For ta comprehensive |
No |
TA- Inferential |
| 04/21/2023 |
3.6.0 |
MIS-84-024-24 |
UPDATE |
For ta inferential |
No |
Yes |
| 04/21/2023 |
3.6.0 |
MIS-84-024-24 |
UPDATE |
Ta min |
|
0 |
| 04/21/2023 |
3.6.0 |
MIS-84-024-24 |
UPDATE |
Ta max |
|
0.98 |
| 04/21/2023 |
3.6.0 |
MIS-84-024-24 |
UPDATE |
Threshold minimum |
TBD |
0 |
| 04/21/2023 |
3.6.0 |
MIS-84-024-24 |
UPDATE |
Threshold maximum |
TBD |
0.98 |
| 04/21/2023 |
3.6.0 |
MIS-84-019-19 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-84-004-4 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-84-003-3 |
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 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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-83-038-38 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-83-032-32 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-83-031-31 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-83-030-30 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-83-029-29 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-83-028-28 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-83-024-24 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-83-022-22 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-83-020-20 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-83-013-13 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-83-011-11 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-83-009-9 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-83-008-8 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-83-006-6 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-83-005-5 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-82-017-17 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-82-014-14 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-82-013-13 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-82-012-12 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-82-011-11 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-81-047-47 |
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: 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 |
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), |
| 04/21/2023 |
3.6.0 |
MIS-81-041-41 |
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: 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 |
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), |
| 04/21/2023 |
3.6.0 |
MIS-81-040-40 |
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: 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 |
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), |
| 04/21/2023 |
3.6.0 |
MIS-81-038-38 |
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: 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 |
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), |
| 04/21/2023 |
3.6.0 |
MIS-81-037-37 |
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: 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 |
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), |
| 04/21/2023 |
3.6.0 |
MIS-81-035-35 |
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: 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 |
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), |
| 04/21/2023 |
3.6.0 |
MIS-81-034-34 |
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: 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 |
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), |
| 04/21/2023 |
3.6.0 |
MIS-81-030-30 |
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: 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 |
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), |
| 04/21/2023 |
3.6.0 |
MIS-81-026-26 |
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: 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 |
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), |
| 04/21/2023 |
3.6.0 |
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: 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 |
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), |
| 04/21/2023 |
3.6.0 |
MIS-81-011-11 |
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: 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 |
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), |
| 04/21/2023 |
3.6.0 |
MIS-81-010-10 |
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: 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 |
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), |
| 04/21/2023 |
3.6.0 |
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: 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 |
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), |
| 04/21/2023 |
3.6.0 |
MIS-81-008-8 |
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: 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 |
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), |
| 04/21/2023 |
3.6.0 |
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: 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 |
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), |
| 04/21/2023 |
3.6.0 |
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: 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 |
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), |
| 04/21/2023 |
3.6.0 |
MIS-80-017-17 |
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: 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 |
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). |
| 04/21/2023 |
3.6.0 |
MIS-80-014-14 |
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: 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 |
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). |
| 04/21/2023 |
3.6.0 |
MIS-80-013-13 |
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: 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 |
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). |
| 04/21/2023 |
3.6.0 |
MIS-80-012-12 |
UPDATE |
Priority |
Medium |
High |
| 04/21/2023 |
3.6.0 |
MIS-80-012-12 |
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: 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 |
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). |
| 04/21/2023 |
3.6.0 |
MIS-80-011-11 |
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: 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 |
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). |
| 04/21/2023 |
3.6.0 |
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: 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 |
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). |
| 04/21/2023 |
3.6.0 |
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: 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 |
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). |
| 04/21/2023 |
3.6.0 |
MIS-79-060-60 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-79-059-59 |
UPDATE |
Priority |
Medium |
High |
| 04/21/2023 |
3.6.0 |
MIS-79-059-59 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-79-054-54 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-79-053-53 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-79-051-51 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-79-050-50 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-79-042-42 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-79-041-41 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-79-037-37 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-79-034-34 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-79-033-33 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-79-012-12 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-79-011-11 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-79-009-9 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-79-004-4 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-79-003-3 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
MIS-79-002-2 |
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: 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 |
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) |
| 04/21/2023 |
3.6.0 |
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: 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 |
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) |
| 03/10/2023 |
3.4.0 |
MIS-28-003-3 |
UPDATE |
Category |
Expenditures |
N/A |
| 03/10/2023 |
3.4.0 |
MIS-28-003-3 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 03/10/2023 |
3.4.0 |
MIS-28-003-3 |
UPDATE |
For ta inferential |
Yes |
No |
| 03/10/2023 |
3.4.0 |
MIS-28-003-3 |
UPDATE |
Threshold minimum |
0 |
N/A |
| 03/10/2023 |
3.4.0 |
MIS-28-003-3 |
UPDATE |
Threshold maximum |
0.02 |
N/A |
| 03/10/2023 |
3.4.0 |
MIS-28-003-3 |
UPDATE |
Annotation |
Numeric |
N/A |
| 03/10/2023 |
3.4.0 |
MIS-28-003-3 |
UPDATE |
Specification |
STEP 1: Active non-duplicate RX claims during DQ 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 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 |
| 04/21/2023 |
3.6.0 |
MIS-26-025-25 |
UPDATE |
Priority |
N/A |
Medium |
| 04/21/2023 |
3.6.0 |
MIS-26-025-25 |
UPDATE |
Category |
N/A |
Utilization |
| 04/21/2023 |
3.6.0 |
MIS-26-025-25 |
UPDATE |
For ta comprehensive |
No |
TA- Inferential |
| 04/21/2023 |
3.6.0 |
MIS-26-025-25 |
UPDATE |
For ta inferential |
No |
Yes |
| 04/21/2023 |
3.6.0 |
MIS-26-025-25 |
UPDATE |
Ta min |
|
0 |
| 04/21/2023 |
3.6.0 |
MIS-26-025-25 |
UPDATE |
Ta max |
|
0.98 |
| 04/21/2023 |
3.6.0 |
MIS-26-025-25 |
UPDATE |
Threshold minimum |
TBD |
0 |
| 04/21/2023 |
3.6.0 |
MIS-26-025-25 |
UPDATE |
Threshold maximum |
TBD |
0.98 |
| 03/10/2023 |
3.4.0 |
MIS-26-005-5 |
UPDATE |
Category |
Expenditures |
N/A |
| 03/10/2023 |
3.4.0 |
MIS-26-005-5 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 03/10/2023 |
3.4.0 |
MIS-26-005-5 |
UPDATE |
For ta inferential |
Yes |
No |
| 03/10/2023 |
3.4.0 |
MIS-26-005-5 |
UPDATE |
Threshold minimum |
0 |
N/A |
| 03/10/2023 |
3.4.0 |
MIS-26-005-5 |
UPDATE |
Threshold maximum |
0.1 |
N/A |
| 03/10/2023 |
3.4.0 |
MIS-26-005-5 |
UPDATE |
Annotation |
Numeric |
N/A |
| 03/10/2023 |
3.4.0 |
MIS-26-005-5 |
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 |
| 03/10/2023 |
3.4.0 |
MIS-24-012-12 |
UPDATE |
Category |
Expenditures |
N/A |
| 03/10/2023 |
3.4.0 |
MIS-24-012-12 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 03/10/2023 |
3.4.0 |
MIS-24-012-12 |
UPDATE |
For ta inferential |
Yes |
No |
| 03/10/2023 |
3.4.0 |
MIS-24-012-12 |
UPDATE |
Threshold minimum |
0 |
N/A |
| 03/10/2023 |
3.4.0 |
MIS-24-012-12 |
UPDATE |
Threshold maximum |
0.02 |
N/A |
| 03/10/2023 |
3.4.0 |
MIS-24-012-12 |
UPDATE |
Annotation |
Numeric |
N/A |
| 03/10/2023 |
3.4.0 |
MIS-24-012-12 |
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 |
| 04/21/2023 |
3.6.0 |
MIS-22-013-13 |
UPDATE |
Priority |
Medium |
High |
| 03/10/2023 |
3.4.0 |
MIS-22-012-12 |
UPDATE |
Category |
Expenditures |
N/A |
| 03/10/2023 |
3.4.0 |
MIS-22-012-12 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 03/10/2023 |
3.4.0 |
MIS-22-012-12 |
UPDATE |
For ta inferential |
Yes |
No |
| 03/10/2023 |
3.4.0 |
MIS-22-012-12 |
UPDATE |
Threshold minimum |
0 |
N/A |
| 03/10/2023 |
3.4.0 |
MIS-22-012-12 |
UPDATE |
Threshold maximum |
0.02 |
N/A |
| 03/10/2023 |
3.4.0 |
MIS-22-012-12 |
UPDATE |
Annotation |
Numeric |
N/A |
| 03/10/2023 |
3.4.0 |
MIS-22-012-12 |
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 |
| 04/21/2023 |
3.6.0 |
MIS-21-059-59 |
UPDATE |
Priority |
Medium |
High |
| 12/09/2022 |
3.0.6 |
RULE-7379 |
UPDATE |
Measure name |
% missing: XXI-MBESCBES-CATEGORY-OF-SERVICE (CRX00003) |
% of non-zero paid claim lines with Title XXI funding with missing XXI-MBESCBES-CATEGORY-OF-SERVICE (CRX00003) |
| 12/09/2022 |
3.0.6 |
RULE-7378 |
UPDATE |
Measure name |
% missing: XXI-MBESCBES-CATEGORY-OF-SERVICE (COT00003) |
% of non-zero paid claim lines with Title XXI funding with missing XXI-MBESCBES-CATEGORY-OF-SERVICE (COT00003) |
| 12/09/2022 |
3.0.6 |
RULE-7377 |
UPDATE |
Measure name |
% missing: XXI-MBESCBES-CATEGORY-OF-SERVICE (CLT00003) |
% of non-zero paid claim lines with Title XXI funding with missing XXI-MBESCBES-CATEGORY-OF-SERVICE (CLT00003) |
| 12/09/2022 |
3.0.6 |
RULE-7376 |
UPDATE |
Measure name |
% missing: XXI-MBESCBES-CATEGORY-OF-SERVICE (CIP00003) |
% of non-zero paid claim lines with Title XXI funding with missing XXI-MBESCBES-CATEGORY-OF-SERVICE (CIP00003) |
| 12/09/2022 |
3.0.6 |
RULE-7375 |
UPDATE |
Measure name |
% missing: XIX-MBESCBES-CATEGORY-OF-SERVICE (CRX00003) |
% of non-zero paid claim lines with Title XIX funding with missing XIX-MBESCBES-CATEGORY-OF-SERVICE (CRX00003) |
| 12/09/2022 |
3.0.6 |
RULE-7374 |
UPDATE |
Measure name |
% missing: XIX-MBESCBES-CATEGORY-OF-SERVICE (COT00003) |
% of non-zero paid claim lines with Title XIX funding with missing XIX-MBESCBES-CATEGORY-OF-SERVICE (COT00003) |
| 12/09/2022 |
3.0.6 |
RULE-7373 |
UPDATE |
Measure name |
% missing: XIX-MBESCBES-CATEGORY-OF-SERVICE (CLT00003) |
% of non-zero paid claim lines with Title XIX funding with missing XIX-MBESCBES-CATEGORY-OF-SERVICE (CLT00003) |
| 12/09/2022 |
3.0.6 |
RULE-7372 |
UPDATE |
Measure name |
% missing: XIX-MBESCBES-CATEGORY-OF-SERVICE (CIP00003) |
% of non-zero paid claim lines with Title XIX funding with missing XIX-MBESCBES-CATEGORY-OF-SERVICE (CIP00003) |
| 12/09/2022 |
3.0.6 |
RULE-810 |
UPDATE |
Category |
Provider identifiers |
Provider information |
| 12/09/2022 |
3.0.6 |
RULE-689 |
UPDATE |
Category |
Provider identifiers |
Provider information |
| 12/22/2022 |
3.1.0 |
Data Elements |
UPDATE |
Description |
Specifications for the data quality measures performed on a file. |
Specifications for all the data elements including valid values and related rules and measures. |
| 12/09/2022 |
3.0.6 |
RULE-1964 |
UPDATE |
Category |
Provider identifiers |
Provider information |
| 12/09/2022 |
3.0.6 |
RULE-1845 |
UPDATE |
Category |
Provider identifiers |
Provider information |
| 12/09/2022 |
3.0.6 |
RULE-1663 |
UPDATE |
Category |
Provider identifiers |
Provider information |
| 12/09/2022 |
3.0.6 |
RULE-1540 |
UPDATE |
Category |
Provider identifiers |
Provider information |
| 12/09/2022 |
3.0.6 |
RULE-1246 |
UPDATE |
Category |
Provider identifiers |
Provider information |
| 12/09/2022 |
3.0.6 |
RULE-1126 |
UPDATE |
Category |
Provider identifiers |
Provider information |
| 12/09/2022 |
3.0.6 |
PRV-6-004-4 |
UPDATE |
Priority |
Medium |
N/A |
| 12/09/2022 |
3.0.6 |
PRV-6-004-4 |
UPDATE |
Category |
Provider identifiers |
N/A |
| 12/09/2022 |
3.0.6 |
PRV-6-004-4 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 12/09/2022 |
3.0.6 |
PRV-6-004-4 |
UPDATE |
For ta inferential |
Yes |
No |
| 12/09/2022 |
3.0.6 |
PRV-6-004-4 |
UPDATE |
Ta min |
0 |
|
| 12/09/2022 |
3.0.6 |
PRV-6-004-4 |
UPDATE |
Ta max |
0.02 |
|
| 12/09/2022 |
3.0.6 |
PRV-6-003-3 |
UPDATE |
Priority |
Medium |
N/A |
| 12/09/2022 |
3.0.6 |
PRV-6-003-3 |
UPDATE |
Category |
Provider identifiers |
N/A |
| 12/09/2022 |
3.0.6 |
PRV-6-003-3 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 12/09/2022 |
3.0.6 |
PRV-6-003-3 |
UPDATE |
For ta inferential |
Yes |
No |
| 12/09/2022 |
3.0.6 |
PRV-6-003-3 |
UPDATE |
Ta min |
0 |
|
| 12/09/2022 |
3.0.6 |
PRV-6-003-3 |
UPDATE |
Ta max |
0.02 |
|
| 12/09/2022 |
3.0.6 |
PRV-6-002-2 |
UPDATE |
Priority |
Medium |
N/A |
| 12/09/2022 |
3.0.6 |
PRV-6-002-2 |
UPDATE |
Category |
Provider identifiers |
N/A |
| 12/09/2022 |
3.0.6 |
PRV-6-002-2 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 12/09/2022 |
3.0.6 |
PRV-6-002-2 |
UPDATE |
For ta inferential |
Yes |
No |
| 12/09/2022 |
3.0.6 |
PRV-6-002-2 |
UPDATE |
Ta min |
0 |
|
| 12/09/2022 |
3.0.6 |
PRV-6-002-2 |
UPDATE |
Ta max |
0.1 |
|
| 12/09/2022 |
3.0.6 |
PRV-6-002-2 |
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 Lookup Designation is "Facility or Group" or 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:1a. PROV-CLASSIFICATION-TYPE and PROVIDER-CLASSIFICATION-CODE match values in Provider Classification lookup tableAND1b. Provider Classification Lookup Designation = “Facility” or "Group"OR2. PROV-CLASSIFICATION-TYPE and PROVIDER-CLASSIFICATION-CODE do not equal to values in Provider Classification lookup tableOR3. PROV-CLASSIFICATION-TYPE is missingOR4. PROVIDER-CLASSIFICATION-CODE is 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 |
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 Lookup Designation is "Facility or Group" or 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:1a. PROV-IDENTIFIER-TYPE and PROVIDER-CLASSIFICATION-CODE match values in Provider Classification lookup tableAND1b. Provider Classification Lookup Designation = “Facility” or "Group"OR2. PROV-IDENTIFIER-TYPE and PROVIDER-CLASSIFICATION-CODE do not equal to values in Provider Classification lookup tableOR3. PROV-IDENTIFIER-TYPE is missingOR4. PROVIDER-CLASSIFICATION-CODE is 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 |
| 12/09/2022 |
3.0.6 |
PRV-6-001-1 |
UPDATE |
Priority |
Medium |
N/A |
| 12/09/2022 |
3.0.6 |
PRV-6-001-1 |
UPDATE |
Category |
Provider identifiers |
N/A |
| 12/09/2022 |
3.0.6 |
PRV-6-001-1 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 12/09/2022 |
3.0.6 |
PRV-6-001-1 |
UPDATE |
For ta inferential |
Yes |
No |
| 12/09/2022 |
3.0.6 |
PRV-6-001-1 |
UPDATE |
Ta min |
0 |
|
| 12/09/2022 |
3.0.6 |
PRV-6-001-1 |
UPDATE |
Ta max |
0.1 |
|
| 12/09/2022 |
3.0.6 |
PRV-6-001-1 |
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 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 Lookup Designation is "Individual" or 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:1a. PROV-CLASSIFICATION-TYPE and PROVIDER-CLASSIFICATION-CODE match values in Provider Classification lookup tableAND1b. Provider Classification Lookup Designation = “Individual”OR2. PROV-CLASSIFICATION-TYPE and PROVIDER-CLASSIFICATION-CODE do not equal to values in Provider Classification lookup tableOR3. PROV-CLASSIFICATION-TYPE is missingOR4. PROVIDER-CLASSIFICATION-CODE is 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 |
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 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 Lookup Designation is "Individual" or 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:1a. PROV-IDENTIFIER-TYPE and PROVIDER-CLASSIFICATION-CODE match values in Provider Classification lookup tableAND1b. Provider Classification Lookup Designation = “Individual”OR2. PROV-IDENTIFIER-TYPE and PROVIDER-CLASSIFICATION-CODE do not equal to values in Provider Classification lookup tableOR3. PROV-IDENTIFIER-TYPE is missingOR4. PROVIDER-CLASSIFICATION-CODE is 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 |
| 01/27/2023 |
3.2.0 |
PRV-2-010-10 |
UPDATE |
Priority |
High |
N/A |
| 01/27/2023 |
3.2.0 |
PRV-2-010-10 |
UPDATE |
Category |
Provider identifiers |
N/A |
| 01/27/2023 |
3.2.0 |
PRV-2-010-10 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 01/27/2023 |
3.2.0 |
PRV-2-010-10 |
UPDATE |
For ta inferential |
Yes |
No |
| 01/27/2023 |
3.2.0 |
PRV-2-010-10 |
UPDATE |
Ta min |
0 |
|
| 01/27/2023 |
3.2.0 |
PRV-2-010-10 |
UPDATE |
Ta max |
0.01 |
|
| 04/21/2023 |
3.6.0 |
PRV-2-009-9 |
UPDATE |
Annotation |
Calculate the percent of submitting-state-provider-IDs that have an NPI, but not a taxonomy code |
Calculate the percent of submitting state provider IDs that have an NPI, but not a taxonomy code |
| 04/21/2023 |
3.6.0 |
PRV-2-009-9 |
UPDATE |
Specification |
STEP 1: Provider enrolled on the last 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 missing STEP 2: Provider identifier 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 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 3: Provider classification type is "NPI"Of the providers that meet the criteria from STEP 2, keep records that satisfy the following criteria: 1. PROV-IDENTIFIER-TYPE = 2STEP 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 is taxonomyOf the providers that meet the criteria from STEP 4, keep records that satisfy the following criteria: 1. PROV-CLASSIFICATION-TYPE is = 1STEP 6: Calculate percent that have a taxonomyDivide the count of unique SUBMITTING-STATE-PROV-IDs from STEP 5 by the count from STEP 3STEP 7: Calculate percent that do not have any taxonomy codesSubtract the percent from STEP 6 from 1 |
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 missing STEP 2: Provider identifier 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 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 3: Provider classification type is "NPI"Of the providers that meet the criteria from STEP 2, keep records that satisfy the following criteria: 1. PROV-IDENTIFIER-TYPE = 2STEP 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 is taxonomyOf the providers that meet the criteria from STEP 4, keep records that satisfy the following criteria: 1. PROV-CLASSIFICATION-TYPE is = 1STEP 6: Calculate percent that have a taxonomyDivide the count of unique SUBMITTING-STATE-PROV-IDs from STEP 5 by the count from STEP 3STEP 7: Calculate percent that do not have any taxonomy codesSubtract the percent from STEP 6 from 1 |
| 04/21/2023 |
3.6.0 |
PRV-2-002-2 |
UPDATE |
Annotation |
N/A |
Calculate the percent of submitting state provider IDs that have an NPI |
| 04/21/2023 |
3.6.0 |
PRV-2-002-2 |
UPDATE |
Specification |
N/A |
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 missing STEP 2: Provider identifier 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 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 3: Provider classification type is "NPI"Of the providers that meet the criteria from STEP 2, keep records that satisfy the following criteria: 1. PROV-IDENTIFIER-TYPE = 2STEP 4: Calculate percent that that have NPIDivide the count of unique SUBMITTING-STATE-PROV-IDs from STEP 3 by the count from STEP 2 |
| 09/06/2023 |
3.12.0 |
MIS-30-003-3 |
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 Capitation Payment: 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 = "2" or "B"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 |
STEP 1: Active non-duplicate OT claims during DQ 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 and S-CHIP Capitation Payment: 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 = "2" or "B"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 |
| 09/06/2023 |
3.12.0 |
MIS-30-002-2 |
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 Capitation Payment: 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 = "2" or "B"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 |
STEP 1: Active non-duplicate OT claims during DQ 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 and S-CHIP Capitation Payment: 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 = "2" or "B"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 |
| 09/06/2023 |
3.12.0 |
MIS-30-001-1 |
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 Capitation Payment: 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 = "2" or "B"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 |
STEP 1: Active non-duplicate OT claims during DQ 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 and S-CHIP Capitation Payment: 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 = "2" or "B"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 |
| 12/09/2022 |
3.0.6 |
MIS-28-001-1 |
UPDATE |
Ta max |
0.02 |
0.1 |
| 12/09/2022 |
3.0.6 |
MIS-28-001-1 |
UPDATE |
Threshold maximum |
0.02 |
0.1 |
| 12/09/2022 |
3.0.6 |
MIS-26-001-1 |
UPDATE |
Ta max |
0.02 |
0.1 |
| 12/09/2022 |
3.0.6 |
MIS-26-001-1 |
UPDATE |
Threshold maximum |
0.02 |
0.1 |
| 12/09/2022 |
3.0.6 |
MIS-24-001-1 |
UPDATE |
Ta max |
0.02 |
0.1 |
| 12/09/2022 |
3.0.6 |
MIS-24-001-1 |
UPDATE |
Threshold maximum |
0.02 |
0.1 |
| 12/09/2022 |
3.0.6 |
MIS-22-001-1 |
UPDATE |
Ta max |
0.02 |
0.1 |
| 12/09/2022 |
3.0.6 |
MIS-22-001-1 |
UPDATE |
Threshold maximum |
0.02 |
0.1 |
| 09/06/2023 |
3.12.0 |
MIS-11-010-10 |
UPDATE |
Active |
True |
False |
| 09/06/2023 |
3.12.0 |
MIS-11-010-10 |
UPDATE |
Annotation |
Alphanumeric |
N/A |
| 09/06/2023 |
3.12.0 |
MIS-11-010-10 |
UPDATE |
Specification |
STEP 1: Any active record segmentKeep all active records from segment (PRV000XX)STEP 2: Alphanumeric missing flagCreate a binary flag called Alphanumeric_Missing that is equal to 1 when1. [DATA-ELEMENT-NAME] does not contain any alpha character (A-Z or a-z) OR any digit 1-9STEP 3: All alphanumeric missingOf the SUBMITTING-STATE-PROV-IDs identified in STEP 1, select those where Alphanumeric_Missing = 1 for all record segments for each particular SUBMITTING-STATE-PROV-IDSTEP 4: Calculate percentageDivide the count of unique SUBMITTING-STATE-PROV-IDs from STEP 3 by the count of unique SUBMITTING-STATE-PROV-IDs from STEP 1 |
N/A |
| 09/06/2023 |
3.12.0 |
MIS-1-092-92 |
UPDATE |
Priority |
High |
N/A |
| 09/06/2023 |
3.12.0 |
MIS-1-092-92 |
UPDATE |
Category |
Beneficiary eligibility |
N/A |
| 09/06/2023 |
3.12.0 |
MIS-1-092-92 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 09/06/2023 |
3.12.0 |
MIS-1-092-92 |
UPDATE |
For ta inferential |
Yes |
No |
| 09/06/2023 |
3.12.0 |
MIS-1-092-92 |
UPDATE |
Ta min |
0 |
|
| 09/06/2023 |
3.12.0 |
MIS-1-092-92 |
UPDATE |
Ta max |
0.02 |
|
| 09/06/2023 |
3.12.0 |
MIS-1-032-32 |
UPDATE |
Priority |
High |
N/A |
| 09/06/2023 |
3.12.0 |
MIS-1-032-32 |
UPDATE |
Category |
Beneficiary eligibility |
N/A |
| 09/06/2023 |
3.12.0 |
MIS-1-032-32 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 09/06/2023 |
3.12.0 |
MIS-1-032-32 |
UPDATE |
For ta inferential |
Yes |
No |
| 09/06/2023 |
3.12.0 |
MIS-1-032-32 |
UPDATE |
Ta min |
0 |
|
| 09/06/2023 |
3.12.0 |
MIS-1-032-32 |
UPDATE |
Ta max |
0.02 |
|
| 09/06/2023 |
3.12.0 |
MIS-1-021-21 |
UPDATE |
Priority |
High |
N/A |
| 09/06/2023 |
3.12.0 |
MIS-1-021-21 |
UPDATE |
Category |
Beneficiary demographics |
N/A |
| 09/06/2023 |
3.12.0 |
MIS-1-021-21 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 09/06/2023 |
3.12.0 |
MIS-1-021-21 |
UPDATE |
For ta inferential |
Yes |
No |
| 09/06/2023 |
3.12.0 |
MIS-1-021-21 |
UPDATE |
Ta min |
0 |
|
| 09/06/2023 |
3.12.0 |
MIS-1-021-21 |
UPDATE |
Ta max |
0.02 |
|
| 09/06/2023 |
3.12.0 |
MIS-1-020-20 |
UPDATE |
Priority |
High |
N/A |
| 09/06/2023 |
3.12.0 |
MIS-1-020-20 |
UPDATE |
Category |
Beneficiary demographics |
N/A |
| 09/06/2023 |
3.12.0 |
MIS-1-020-20 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 09/06/2023 |
3.12.0 |
MIS-1-020-20 |
UPDATE |
For ta inferential |
Yes |
No |
| 09/06/2023 |
3.12.0 |
MIS-1-020-20 |
UPDATE |
Ta min |
0 |
|
| 09/06/2023 |
3.12.0 |
MIS-1-020-20 |
UPDATE |
Ta max |
0.02 |
|
| 09/06/2023 |
3.12.0 |
MIS-1-006-6 |
UPDATE |
Priority |
High |
N/A |
| 09/06/2023 |
3.12.0 |
MIS-1-006-6 |
UPDATE |
Category |
Beneficiary demographics |
N/A |
| 09/06/2023 |
3.12.0 |
MIS-1-006-6 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 09/06/2023 |
3.12.0 |
MIS-1-006-6 |
UPDATE |
For ta inferential |
Yes |
No |
| 09/06/2023 |
3.12.0 |
MIS-1-006-6 |
UPDATE |
Ta min |
0 |
|
| 09/06/2023 |
3.12.0 |
MIS-1-006-6 |
UPDATE |
Ta max |
0.1 |
|
| 09/06/2023 |
3.12.0 |
MIS-1-001-1 |
UPDATE |
Priority |
High |
N/A |
| 09/06/2023 |
3.12.0 |
MIS-1-001-1 |
UPDATE |
Category |
Beneficiary demographics |
N/A |
| 09/06/2023 |
3.12.0 |
MIS-1-001-1 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 09/06/2023 |
3.12.0 |
MIS-1-001-1 |
UPDATE |
For ta inferential |
Yes |
No |
| 09/06/2023 |
3.12.0 |
MIS-1-001-1 |
UPDATE |
Ta min |
0 |
|
| 09/06/2023 |
3.12.0 |
MIS-1-001-1 |
UPDATE |
Ta max |
0.02 |
|
| 04/21/2023 |
3.6.0 |
MCR-9-006_1-18 |
UPDATE |
Measure name |
% of PCCM (TYPE-OF-SERVICE) capitated payments with a non-missing plan ID that do not have a corresponding managed care participation PCCM plan |
% of PCCM (TYPE-OF-SERVICE) capitation payments with a non-missing plan ID that do not have a corresponding managed care participation PCCM plan |
| 04/21/2023 |
3.6.0 |
MCR-9-006_1-18 |
UPDATE |
Annotation |
Calculate the percentage of PCCM capitated payments with a non-missing Plan Id that do not have a corresponding managed care participation PCCM plan |
Calculate the percentage of PCCM capitation payments with a non-missing plan id that do not have a corresponding managed care participation PCCM plan |
| 04/21/2023 |
3.6.0 |
MCR-9-006_1-18 |
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 = "120"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 PCCM 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 "02" 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 |
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 = "120"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 PCCM 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 "02" or "03" 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 |
| 04/21/2023 |
3.6.0 |
MCR-64-004-4 |
UPDATE |
Priority |
High |
N/A |
| 04/21/2023 |
3.6.0 |
MCR-64-004-4 |
UPDATE |
Annotation |
Calculate the percentage of Medicaid and S-CHIP encounter: original and adjustment, crossover, paid RX claims where Medicare paid amount, total Medicare coinsurance amount, and total Medicare deductible amount are equal to 0 or are missing |
N/A |
| 04/21/2023 |
3.6.0 |
MCR-64-004-4 |
UPDATE |
Specification |
STEP 1: Active non-duplicate RX records during DQ report monthDefine the RX records universe at the header level by importing both headers and lines that satisfy the following criteria:For Headers: 1. Reporting Period for the filename = DQ report month2. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing3. CLAIM-DENIED-INDICATOR is not equal to "0" or is missing4. TYPE-OF-CLAIM is not equal to "Z" or is missing5. CLAIM-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing6. No Header Duplicates: Duplicates are dropped at the header-level, if the following four data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND.For Lines:1. Reporting Period from the filename = DQ report month2. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing3. No Line Duplicates: Duplicates are dropped at the line level if the following data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, LINE-NUM-ORIG, LINE-NUM-ADJ, and LINE-ADJSTMT-IND.4. Lines merge to a header using ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND=LINE-ADJSTMT-IND.STEP 2: Medicaid and S-CHIP Encounter: Original and Adjustment, Crossover, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "3" or "C"2. CROSSOVER-IND = "1"STEP 3: No Medicare AmountsOf the claims that meet the criteria from STEP 2, further restrict them by the following criteria: 1. MEDICARE-PAID-AMT = 0 or is missing on all lines2. TOT-MEDICARE-COINS-AMT = 0 or is missing3. TOT-MEDICARE-DEDUCTIBLE-AMT = 0 or is missingSTEP 4: Calculate percentageDivide the count of claim headers from STEP 3 by the count of claim headers from STEP 2 |
N/A |
| 04/21/2023 |
3.6.0 |
MCR-64-003-3 |
UPDATE |
Priority |
High |
N/A |
| 04/21/2023 |
3.6.0 |
MCR-64-003-3 |
UPDATE |
Annotation |
Calculate the percentage of Medicaid and S-CHIP encounter: original and adjustment, crossover, paid OT claims where Medicare paid amount, total Medicare coinsurance amount, and total Medicare deductible amount are equal to 0 or are missing |
N/A |
| 04/21/2023 |
3.6.0 |
MCR-64-003-3 |
UPDATE |
Specification |
STEP 1: Active non-duplicate OT records during DQ report monthDefine the OT records universe at the header level by importing both headers and lines that satisfy the following criteria:For Headers: 1. Reporting Period for the filename = DQ report month2. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing3. CLAIM-DENIED-INDICATOR is not equal to "0" or is missing4. TYPE-OF-CLAIM is not equal to "Z" or is missing5. CLAIM-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing6. No Header Duplicates: Duplicates are dropped at the header-level, if the following four data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND.For Lines:1. Reporting Period from the filename = DQ report month2. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing3. No Line Duplicates: Duplicates are dropped at the line level if the following data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, LINE-NUM-ORIG, LINE-NUM-ADJ, and LINE-ADJSTMT-IND.4. Lines merge to a header using ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND=LINE-ADJSTMT-IND.STEP 2: Medicaid and S-CHIP Encounter: Original and Adjustment, Crossover, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "3" or "C"2. CROSSOVER-IND = "1"STEP 3: No Medicare AmountsOf the claims that meet the criteria from STEP 2, further restrict them by the following criteria: 1. MEDICARE-PAID-AMT = 0 or is missing on all lines2. TOT-MEDICARE-COINS-AMT = 0 or is missing3. TOT-MEDICARE-DEDUCTIBLE-AMT = 0 or is missingSTEP 4: Calculate percentageDivide the count of claim headers from STEP 3 by the count of claim headers from STEP 2 |
N/A |
| 04/21/2023 |
3.6.0 |
MCR-64-002-2 |
UPDATE |
Priority |
High |
N/A |
| 04/21/2023 |
3.6.0 |
MCR-64-002-2 |
UPDATE |
Annotation |
Calculate the percentage of Medicaid and S-CHIP encounter: original and adjustment, crossover, paid LT claims where Medicare paid amount, total Medicare coinsurance amount, and total Medicare deductible amount are equal to 0 or are missing |
N/A |
| 04/21/2023 |
3.6.0 |
MCR-64-002-2 |
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: Medicaid and S-CHIP Encounter: Original and Adjustment, Crossover, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "3" or "C"2. CROSSOVER-IND = "1"STEP 3: No Medicare Amounts Of the claims that meet the criteria from STEP 2, further restrict them by the following criteria: 1. MEDICARE-PAID-AMT = 0 or is missing2. TOT-MEDICARE-COINS-AMT = 0 or is missing3. TOT-MEDICARE-DEDUCTIBLE-AMT = 0 or is missingSTEP 4: Calculate percentageDivide the count of claim headers from STEP 3 by the count of claim headers from STEP 2 |
N/A |
| 04/21/2023 |
3.6.0 |
MCR-64-001-1 |
UPDATE |
Priority |
High |
N/A |
| 04/21/2023 |
3.6.0 |
MCR-64-001-1 |
UPDATE |
Annotation |
Calculate the percentage of Medicaid and S-CHIP encounter: original and adjustment, crossover, paid IP claims where Medicare paid amount, total Medicare coinsurance amount, and total Medicare deductible amount are equal to 0 or are missing |
N/A |
| 04/21/2023 |
3.6.0 |
MCR-64-001-1 |
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: Medicaid and S-CHIP Encounter: Original and Adjustment, Crossover, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "3" or "C"2. CROSSOVER-IND = "1"STEP 3: No Medicare AmountsOf the claims that meet the criteria from STEP 2, further restrict them by the following criteria: 1. MEDICARE-PAID-AMT = 0 or is missing2. TOT-MEDICARE-COINS-AMT = 0 or is missing3. TOT-MEDICARE-DEDUCTIBLE-AMT = 0 or is missingSTEP 4: Calculate percentageDivide the count of claim headers from STEP 3 by the count of claim headers from STEP 2 |
N/A |
| 04/21/2023 |
3.6.0 |
MCR-63-004-4 |
UPDATE |
Priority |
High |
N/A |
| 04/21/2023 |
3.6.0 |
MCR-63-004-4 |
UPDATE |
Category |
Expenditures |
N/A |
| 04/21/2023 |
3.6.0 |
MCR-63-004-4 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 04/21/2023 |
3.6.0 |
MCR-63-004-4 |
UPDATE |
For ta inferential |
Yes |
No |
| 04/21/2023 |
3.6.0 |
MCR-63-004-4 |
UPDATE |
Ta min |
0 |
|
| 04/21/2023 |
3.6.0 |
MCR-63-004-4 |
UPDATE |
Ta max |
0.001 |
|
| 04/21/2023 |
3.6.0 |
MCR-63-004-4 |
UPDATE |
Adjustment type |
All Adjustment Types |
Original and Replacement |
| 04/21/2023 |
3.6.0 |
MCR-63-004-4 |
UPDATE |
Annotation |
Calculate the percentage of Medicaid and S-CHIP encounter: original and adjustment, non-crossover, paid RX claims where Medicare paid amount, total Medicare coinsurance amount, or total Medicare deductible amount is non-zero |
N/A |
| 04/21/2023 |
3.6.0 |
MCR-63-004-4 |
UPDATE |
Specification |
STEP 1: Active non-duplicate RX records during DQ report monthDefine the RX records universe at the header level by importing both headers and lines that satisfy the following criteria:For Headers:1. Reporting Period for the filename = DQ report month2. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing3. CLAIM-DENIED-INDICATOR is not equal to "0" or is missing4. TYPE-OF-CLAIM is not equal to "Z" or is missing5. CLAIM-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing6. No Header Duplicates: Duplicates are dropped at the header-level, if the following four data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND.For Lines:1. Reporting Period from the filename = DQ report month2. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing3. No Line Duplicates: Duplicates are dropped at the line level if the following data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, LINE-NUM-ORIG, LINE-NUM-ADJ, and LINE-ADJSTMT-IND.4. Lines merge to a header using ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND=LINE-ADJSTMT-IND.STEP 2: Medicaid and S-CHIP Encounter: Original and Adjustment, Non-Crossover, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "3" or "C"2. CROSSOVER-INDICATOR = "0" or is missingSTEP 3: Non-zero Medicare AmountsOf the claims that meet the criteria from STEP 2, further restrict them by the following criteria:1a. MEDICARE-PAID-AMT is non-zero on any lineOR1b. TOT-MEDICARE-COINS-AMT is non-zeroOR 1c. TOT-MEDICARE-DEDUCTIBLE-AMT is non-zeroSTEP 4: Calculate percentageDivide the count of claim headers from STEP 3 by the count of claim headers in STEP 2 |
N/A |
| 04/21/2023 |
3.6.0 |
MCR-63-003-3 |
UPDATE |
Priority |
High |
N/A |
| 04/21/2023 |
3.6.0 |
MCR-63-003-3 |
UPDATE |
Category |
Expenditures |
N/A |
| 04/21/2023 |
3.6.0 |
MCR-63-003-3 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 04/21/2023 |
3.6.0 |
MCR-63-003-3 |
UPDATE |
For ta inferential |
Yes |
No |
| 04/21/2023 |
3.6.0 |
MCR-63-003-3 |
UPDATE |
Ta min |
0 |
|
| 04/21/2023 |
3.6.0 |
MCR-63-003-3 |
UPDATE |
Ta max |
0.001 |
|
| 04/21/2023 |
3.6.0 |
MCR-63-003-3 |
UPDATE |
Annotation |
Calculate the percentage of Medicaid and S-CHIP encounter: original and adjustment, non-crossover, paid OT claims where Medicare paid amount, total Medicare coinsurance amount, or total Medicare deductible amount is non-zero |
N/A |
| 04/21/2023 |
3.6.0 |
MCR-63-003-3 |
UPDATE |
Specification |
STEP 1: Active non-duplicate OT records during DQ report monthDefine the OT records universe at the header level by importing both headers and lines that satisfy the following criteria:For Headers:1. Reporting Period for the filename = DQ report month2. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing3. CLAIM-DENIED-INDICATOR is not equal to "0" or is missing4. TYPE-OF-CLAIM is not equal to "Z" or is missing5. CLAIM-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing6. No Header Duplicates: Duplicates are dropped at the header-level, if the following four data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND.For Lines:1. Reporting Period from the filename = DQ report month2. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing3. No Line Duplicates: Duplicates are dropped at the line level if the following data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, LINE-NUM-ORIG, LINE-NUM-ADJ, and LINE-ADJSTMT-IND.4. Lines merge to a header using ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND=LINE-ADJSTMT-IND.STEP 2: Medicaid and S-CHIP Encounter: Original and Adjustment, Non-Crossover, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "3" or "C"2. CROSSOVER-INDICATOR = "0" or is missingSTEP 3: Non-zero Medicare AmountsOf the claims that meet the criteria from STEP 2, further restrict them by the following criteria:1a. MEDICARE-PAID-AMT is non-zero on any lineOR1b. TOT-MEDICARE-COINS-AMT is non-zeroOR 1c. TOT-MEDICARE-DEDUCTIBLE-AMT is non-zeroSTEP 4: Calculate percentageDivide the count of claim headers from STEP 3 by the count of claim headers in STEP 2 |
N/A |
| 04/21/2023 |
3.6.0 |
MCR-63-002-2 |
UPDATE |
Priority |
High |
N/A |
| 04/21/2023 |
3.6.0 |
MCR-63-002-2 |
UPDATE |
Category |
Expenditures |
N/A |
| 04/21/2023 |
3.6.0 |
MCR-63-002-2 |
UPDATE |
For ta comprehensive |
TA- Inferential |
No |
| 04/21/2023 |
3.6.0 |
MCR-63-002-2 |
UPDATE |
For ta inferential |
Yes |
No |
| 04/21/2023 |
3.6.0 |
MCR-63-002-2 |
UPDATE |
Ta min |
0 |
|
| 04/21/2023 |
3.6.0 |
MCR-63-002-2 |
UPDATE |
Ta max |
0.001 |
|
| 04/21/2023 |
3.6.0 |
MCR-63-002-2 |
UPDATE |
Annotation |
Calculate the percentage of Medicaid and S-CHIP encounter: original and adjustment, non-crossover, paid LT claims where Medicare paid amount, total Medicare coinsurance amount, or total Medicare deductible amount is non-zero |
N/A |
| 04/21/2023 |
3.6.0 |
MCR-63-002-2 |
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: Medicaid and S-CHIP Encounter: Original and Adjustment, Non-Crossover, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "3" or "C"2. CROSSOVER-INDICATOR = "0" or is missingSTEP 3: Non-zero Medicare AmountsOf the claims that meet the criteria from STEP 2, further restrict them by the following criteria:1a. MEDICARE-PAID-AMT is non-zeroOR1b. TOT-MEDICARE-COINS-AMT is non-zeroOR 1c. TOT-MEDICARE-DEDUCTIBLE-AMT is non-zeroSTEP 4: Calculate percentageDivide the count of claim headers from STEP 3 by the count of claim headers in STEP 2 |
N/A |
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