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TMSIS Dataguide Medicaid.gov

Version:

4.0.20

FFS-S-018-7

Data Quality Measure
Last updated

No Updates

Key Information

Measure Name % of total original claim lines that are crossover claims
File Type COT
Measure ID FFS-S-018-7
Measure Type Claims Percentage
Content area FFS

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 All Indicators

Thresholds

Minimum N/A
Maximum N/A
TA Minimun
TA Maximum
Longitudinal Threshold 0.25
For TA
(for including in compliance training) 		No
For TA
(Longitudinal) 		No

Data Elements

DD Data Element CROSSOVER-INDICATOR
DD Data Element Number COT023

Annotation Calculate the percentage of Medicaid FFS: original, paid OT claims that are crossover claims
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:

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 FFS: Original, Paid Claims

Of the claim that meet the criteria from STEP 1, further restrict them by the following criteria:

1. TYPE-OF-CLAIM = "1"

2. ADJUSTMENT-IND = "0"



STEP 3: Medicaid FFS: Original, Crossover, Paid Claims

Of the claims that meet the criteria from STEP 2, select crossover claims:

1. CROSSOVER-INDICATOR = "1"



STEP 4 : Calculate percentage for measure

Divide the count of claim lines from STEP 3 by the count of claim lines from STEP 2