ALL-12-001-1

An official website of the United States government

Official websites use .gov
A .gov website belongs to an official government organization in the United States.

Secure .gov websites use HTTPS
A lock () or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites.

Measure Name	% of claim headers with PROGRAM TYPE = 01, 02, or 04 (EPSDT, family planning, or FQHC)
File Type	COT
Measure ID	ALL-12-001-1
Measure Type	Claims Percentage
Content area	ALL

Validation Type	Inferential

Measure Priority	Medium
Focus Area	N/A
Category	Utilization

Claim Type	Medicaid,FFS or Medicaid,Enc or CHIP,FFS or CHIP,Enc
Adjustment Type	Original
Crossover Type	Non-Crossover

Minimum	0.01
Maximum	0.15
TA Minimun	0.01
TA Maximum	0.15
Longitudinal Threshold	N/A
For TA (for including in compliance training)	TA- Inferential
For TA (Longitudinal)	No

DD Data Element	PROGRAM-TYPE
DD Data Element Number	COT065

Annotation	N/A
Specification	N/A

Published Date	Data Guide Version	DQM	Action	Field	Before	After
11/20/2025	4.0.22	ALL-12-001-1	UPDATE	Annotation	Calculate the percentage of Medicaid and S-CHIP FFS and Encounter: original and adjustment, paid OT claims that are classified as EPSDT, family planning, or FQHC according to program type	N/A
11/20/2025	4.0.22	ALL-12-001-1	UPDATE	Specification	STEP 1: Active non-duplicate OT records during DQ report monthDefine the OT 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 FFS and 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 = "1" or "3" or "A" or "C"2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "0" or is missingSTEP 3: EPSDT, Family planning, FQHCOf the claims that meet the criteria from STEP 2, limit to those that satisfy the following criterion:1. PROGRAM-TYPE = "01" or "02" or "04"STEP 4: Calculate percentageDivide the count of claims from STEP 3 by the count in STEP 2	N/A
04/24/2025	4.0.7	ALL-12-001-1	ADD	N/A		Created

ALL-12-001-1

Key Information

Validation

Measure Priority

Claim Information

Thresholds

Data Elements