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TMSIS Dataguide Medicaid.gov

Version:

4.0.20

MCR-32-009-9

Data Quality Measure
Last updated

No Updates

Key Information

Measure Name % of claim headers without a valid Adjustment Indicator (ADJ-IND is 2, 3, 9, other invalid value, or missing)
File Type CRX
Measure ID MCR-32-009-9
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
Maximum 0.001
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 ADJUSTMENT-IND
DD Data Element Number CRX025

Annotation Calculate the percentage of unique header records associated with Medicaid Encounter: original and adjustment, paid RX claims with an invalid or missing adjustment indicator value
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: Total Count

Of the claims that meet the criteria from STEP 2, count the number of unique header records.



STEP 4: Count invalid adjustment indicators

From the records from STEP 2, count unique header records with ADJUSTMENT-IND not equal to ("0", "1", "4", "5", "6") or is missing



STEP 5: Percentage

Divide the count of unique header records from STEP 4 by the count in STEP 3