EXP-31-001-1

Key Information

Measure Name	% of claim headers with Total Medicaid Paid Amount = $0 or missing
File Type	CIP
Measure ID	EXP-31-001-1
Measure Type	Claims percentage
Content area	MCR MULTI EXP

Measure Name

% of claim headers with Total Medicaid Paid Amount = $0 or missing

File Type

CIP

Measure ID

EXP-31-001-1

Measure Type

Claims percentage

Content area

MCR MULTI EXP

Validation

Validation Type	Inferential

Validation Type

Inferential

Measure Priority

Measure Priority	High
Focus Area	Managed care
Category	Expenditures

High

Focus Area

Managed care

Category

Expenditures

Claim Information

Claim Type	CHIP,Enc
Adjustment Type	Original
Crossover Type	Non-Crossover

Claim Type

CHIP,Enc

Adjustment Type

Original

Crossover Type

Non-Crossover

Thresholds

Minimum	0
Maximum	0.05
TA Minimun	0
TA Maximum	0.1
Longitudinal Threshold	0.2
For TA (for including in compliance training)	TA- Inferential
For TA (Longitudinal)	No

Minimum

Maximum

0.05

TA Minimun

TA Maximum

0.1

Longitudinal Threshold

0.2

For TA
(for including in compliance training)

TA- Inferential

For TA
(Longitudinal)

Data Elements

DD Data Element	TOT-MEDICAID-PAID-AMT
DD Data Element Number	CIP114

DD Data Element

TOT-MEDICAID-PAID-AMT

DD Data Element Number

CIP114

Annotation	Calculate the percentage of S-CHIP Encounter: original, non-crossover, paid IP claims where total Medicaid paid amount is equal to $0 or missing
Specification	STEP 1: Active non-duplicate paid IP claims during report month Define the IP 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: S-CHIP Encounter: 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 = "C" 2. ADJUSTMENT-IND = "0" 3. CROSSOVER-INDICATOR = "0" or is missing STEP 3: Exclude sub-capitation encounters 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: Total Medicaid paid $0 or missing Of the claims that meet the criteria from STEP 3, restrict to claims that meet the following criteria: 1. TOT-MEDICAID-PAID-AMT = "0" or is missing STEP 5: Calculate percentage Divide the number of claims from STEP 4 by the number of claims from STEP 3.

Annotation

Calculate the percentage of S-CHIP Encounter: original, non-crossover, paid IP claims where total Medicaid paid amount is equal to $0 or missing

Specification

STEP 1: Active non-duplicate paid IP claims during report month

Define the IP 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: S-CHIP Encounter: 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 = "C"

2. ADJUSTMENT-IND = "0"

3. CROSSOVER-INDICATOR = "0" or is missing

STEP 3: Exclude sub-capitation encounters

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: Total Medicaid paid $0 or missing

Of the claims that meet the criteria from STEP 3, restrict to claims that meet the following criteria:

1. TOT-MEDICAID-PAID-AMT = "0" or is missing

STEP 5: Calculate percentage

Divide the number of claims from STEP 4 by the number of claims from STEP 3.

Published Date	Data Guide Version	DQM	Action	Field	Before	After
04/21/2023	3.6.0	EXP-31-001-1	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, 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: Total Medicaid paid $0 or missingOf the claims that meet the criteria from STEP 2, restrict to claims that meet the following criteria:1. TOT-MEDICAID-PAID-AMT = "0" or is missingSTEP 4: Calculate percentageDivide the number of claims from STEP 3 by the number of claims 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: 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: Total Medicaid paid $0 or missingOf the claims that meet the criteria from STEP 3, restrict to claims that meet the following criteria:1. TOT-MEDICAID-PAID-AMT = "0" or is missingSTEP 5: Calculate percentageDivide the number of claims from STEP 4 by the number of claims from STEP 3.