EXP-37-001_1-2

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TMSIS Dataguide

Medicaid.gov

Version:

EXP-37-001_1-2

Data Quality Measure

Last updated

Key Information

Measure Name	% of claim lines on claims where Payment Level Indicator = 2 with Medicaid Paid Amount = $0 or missing
File Type	COT
Measure ID	EXP-37-001_1-2
Measure Type	Claims percentage
Content area	MCR MULTI EXP

Validation

Validation Type	Inferential

Measure Priority

Measure Priority	High
Focus Area	Managed care
Category	Expenditures

Claim Information

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

Thresholds

Minimum	0
Maximum	0.3
TA Minimun	0
TA Maximum	0.3
Longitudinal Threshold	N/A
For TA (for including in compliance training)	TA- Inferential
For TA (Longitudinal)	No

Data Elements

DD Data Element	PAYMENT-LEVEL-IND • MEDICAID-PAID-AMT
DD Data Element Number	COT068 • COT178

Annotation

Calculate the percentage of Medicaid Encounter: original, non-crossover, paid OT claims billed at the line level that have Medicaid paid amount equal to $0 or missing

Specification

STEP 1: Active non-duplicate OT claims during DQ report month

Define 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 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.

For Lines:

1. Reporting Period from the filename = DQ report month

2. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing

3. 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 Claims

Of 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 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: Payment at the line level

Of the claims from STEP 3, select records where:

1. PAYMENT-LEVEL-IND = "2"

STEP 5: Medicaid paid $0 or missing

Of the claims from STEP 4, select records where:

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

STEP 6: Calculate the percentage for the measure

Divide the count of claim lines from STEP 5 by the count of claims lines from STEP 4.

Published Date	Data Guide Version	DQM	Action	Field	Before	After
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
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