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TMSIS Dataguide Medicaid.gov

Version:

4.0.20

MCR-31-005-5

Data Quality Measure
Last updated

No Updates

Key Information

Measure Name % of MSIS IDs enrolled on Prescription Fill Date
File Type Multiple Files
Measure ID MCR-31-005-5
Measure Type Claims percentage
Content area MCR

Validation

Validation Type Inferential

Measure Priority

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

Claim Information

Claim Type Medicaid,Enc
Adjustment Type All Adjustment Types
Crossover Type All Indicators

Thresholds

Minimum 0.95
Maximum 1
TA Minimun
TA Maximum
Longitudinal Threshold N/A
For TA
(for including in compliance training) 		No
For TA
(Longitudinal) 		No

Data Elements

DD Data Element MSIS-IDENTIFICATION-NUM • PRESCRIPTION-FILL-DATE • MSIS-IDENTIFICATION-NUM • ENROLLMENT-EFF-DATE • ENROLLMENT-END-DATE
DD Data Element Number CRX022 • CRX085 • ELG251 • ELG253 • ELG254

Annotation Calculate the percentage of MSIS IDs on Medicaid Encounter: original and adjustment, paid RX claims that can be found on an Eligible file enrollment time span segment that spans the prescription fill date on the claims file
Specification STEP 1: Active non-duplicate RX records during DQ report month

Define the RX records universe at the header level that satisfy the following criteria:

1. Reporting Period for 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 Encounter: Original and Adjustment, Paid Claims

Of 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 prescription fill date

Of the claims that meet the criteria from STEP 2, restrict to non-missing PRESCRIPTION-FILL-DATE



STEP 4: Eligible any time and links to claims

Define the ENROLLMENT-TIME-SPAN-ELG00021 file segment records that have an MSIS-ID that links to one of the claims identified in STEP 3



STEP 5: Eligible during prescription fill date

Further refine the eligible population by linking on MSIS-ID and keeping records that satisfy the following criteria:

1. Claims PRESCRIPTION-FILL-DATE >= ENROLLMENT-EFF-DATE

2. Claims PRESCRIPTION-FILL-DATE <= ENROLLMENT-END DATE OR ENROLLMENT-END DATE is missing



STEP 6: Unique MSIS-IDs in eligibility

From the MSIS-IDs in STEP 5, limit to unique MSIS-IDs



STEP 7: Unique MSIS-IDs in claims

Of the claims that meet the criteria from STEP 3, limit to unique MSIS-IDs



STEP 8: Calculate percentage

Divide the count of MSIS-IDs from STEP 6 by the count of MSIS-IDs from STEP 7