Key Information

Measure Name	Average Total Medicaid Paid Amount (excludes outliers with Total Medicaid Paid Amount > $300,000)
File Type	CRX
Measure ID	EXP-16-011-4
Measure Type	Average
Content area	EXP

Validation

Validation Type	Longitudinal and Inferential

Measure Priority

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

Claim Information

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

Thresholds

Minimum	20
Maximum	100
TA Minimun
TA Maximum
Longitudinal Threshold	0.15
For TA (for including in compliance training)	No
For TA (Longitudinal)	No

Data Elements

DD Data Element	TOT-MEDICAID-PAID-AMT
DD Data Element Number	CRX041

Annotation

Calculate the average amount paid (excluding outliers with Medicaid Amount Paid > $2 million) for Medicaid FFS: original, non-crossover, paid RX claims

Specification

STEP 1: Active non-duplicate paid RX claims during report month Define the RX claims universe at the header level that satisfy the following criteria: 1. Reporting Period from the filename = DQ report month 2. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing 3. CLAIM-DENIED-INDICATOR is not equal to "0" or is missing 4. TYPE-OF-CLAIM is not equal to "Z" or is missing 5. CLAIM-STATUS is not equal to ("26","026","87","087","542","585", "654") or is missing 6. No Header Duplicates: Duplicates are dropped at the header level, if the following four data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND. STEP 2: Medicaid FFS Payment: Original, Non-Crossover, Paid Claims Of the claims that meet the criteria from STEP 1, further restrict them by the following criteria: 1. TYPE-OF-CLAIM = "1" 2. ADJUSTMENT-IND = "0" 3. CROSSOVER-INDICATOR = "0" or is missing STEP 3: Paid amounts less than $300,000 Of the records that meet the criteria from STEP 2, further restrict them to those with: 1. TOT-MEDICAID-PAID-AMT< 300,000 STEP 4: Average 1. Of the records that meet the criteria in STEP 3, take the average of TOT-MEDICAID-PAID-AMT