MCR-59-006-6

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TMSIS Dataguide

Medicaid.gov

Version:

MCR-59-006-6

Data Quality Measure

Last updated

Key Information

Measure Name	% of claim headers that have Total Medicaid Paid Amount greater than a non-zero Total Allowed Amount
File Type	CLT
Measure ID	MCR-59-006-6
Measure Type	Claims Percentage
Content area	MCR

Validation

Validation Type	Inferential

Measure Priority

Measure Priority	High
Focus Area	Managed care
Category	Expenditures

Claim Information

Claim Type	Medicaid,Enc or CHIP,Enc
Adjustment Type	Original
Crossover Type	All Indicators

Thresholds

Minimum	0
Maximum	0.05
TA Minimun	0
TA Maximum	0.05
Longitudinal Threshold	N/A
For TA (for including in compliance training)	TA- Inferential
For TA (Longitudinal)	No

Data Elements

DD Data Element	TOT-MEDICAID-PAID-AMT • TOT-ALLOWED-AMT
DD Data Element Number	CLT065 • CLT064

Annotation

Calculate the percentage of Medicaid and S-CHIP Encounter: original, paid LT claims where the total Medicaid paid amount is greater than the total allowed amount

Specification

STEP 1: Active non-duplicate LT records during DQ report month

Define the LT 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 and S-CHIP Encounter: Original, Paid Claims

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

1. TYPE-OF-CLAIM = "3" or "C"

2. ADJUSTMENT-IND = "0"

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: Non-missing total Medicaid paid and allowed amounts

Of the records from STEP 3, further refine the population with the following criteria:

1. TOT-MEDICAID-PAID-AMT is not missing

2. TOT-ALLOWED-AMT is not missing

3. TOT-ALLOWED-AMT is not equal to 0

STEP 5: Total Medicaid paid is greater than total allowed

Of the records from STEP 4, further refine the population with the following criteria:

1. TOT-MEDICAID-PAID-AMT > TOT-ALLOWED-AMT

STEP 6: Percentage

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

Published Date	Data Guide Version	DQM	Action	Field	Before	After
04/21/2023	3.6.0	MCR-59-006-6	UPDATE	Specification	STEP 1: Active non-duplicate LT records during DQ report monthDefine the LT records universe at the header level that satisfy the following criteria:1. Reporting Period for 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: Medicaid and S-CHIP Encounter: Original, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "3" or "C"2. ADJUSTMENT-IND = "0"STEP 3: Non-missing total Medicaid paid and allowed amountsOf the records from STEP 2, further refine the population with the following criteria: 1. TOT-MEDICAID-PAID-AMT is not missing2. TOT-ALLOWED-AMT is not missing3. TOT-ALLOWED-AMT is not equal to 0STEP 4: Total Medicaid paid is greater than total allowed Of the records from STEP 3, further refine the population with the following criteria:1. TOT-MEDICAID-PAID-AMT > TOT-ALLOWED-AMTSTEP 5: PercentageDivide the count of claims from STEP 4 by the count of claims from STEP 3	STEP 1: Active non-duplicate LT records during DQ report monthDefine the LT records universe at the header level that satisfy the following criteria:1. Reporting Period for 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: Medicaid and S-CHIP Encounter: Original, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "3" or "C"2. ADJUSTMENT-IND = "0"STEP 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: Non-missing total Medicaid paid and allowed amountsOf the records from STEP 3, further refine the population with the following criteria: 1. TOT-MEDICAID-PAID-AMT is not missing2. TOT-ALLOWED-AMT is not missing3. TOT-ALLOWED-AMT is not equal to 0STEP 5: Total Medicaid paid is greater than total allowed Of the records from STEP 4, further refine the population with the following criteria:1. TOT-MEDICAID-PAID-AMT > TOT-ALLOWED-AMTSTEP 6: PercentageDivide the count of claims from STEP 5 by the count of claims from STEP 4.