ALL-13-002-2

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TMSIS Dataguide

Medicaid.gov

Version:

ALL-13-002-2

Data Quality Measure

Last updated

Key Information

Measure Name	% of MSIS IDs limited to family planning (RESTRICTED-BENEFITS-CODE = 6) with non-family planning services (PROGRAM-TYPE not equal 2)
File Type	Multiple Files
Measure ID	ALL-13-002-2
Measure Type	Claims Percentage
Content area	ALL

Validation

Validation Type	Inferential

Measure Priority

Measure Priority	High
Focus Area	N/A
Category	Beneficiary eligibility

Claim Information

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

Thresholds

Minimum	0
Maximum	0.15
TA Minimun	0
TA Maximum	0.15
Longitudinal Threshold	N/A
For TA (for including in compliance training)	TA- Inferential
For TA (Longitudinal)	No

Data Elements

DD Data Element	ELIGIBILITY-DETERMINANT-EFF-DATE • ELIGIBILITY-DETERMINANT-END-DATE • PROGRAM-TYPE • RESTRICTED-BENEFITS-CODE • MSIS-IDENTIFICATION-NUM • PRESCRIPTION-FILL-DATE • MSIS-IDENTIFICATION-NUM
DD Data Element Number	ELG099 • ELG100 • CRX055 • ELG097 • ELG251 • CRX085 • CRX022

Annotation	N/A
Specification	N/A

Published Date	Data Guide Version	DQM	Action	Field	Before	After
11/20/2025	4.0.22	ALL-13-002-2	UPDATE	Annotation	Calculate the percentage of MSIS IDs on Medicaid FFS and Encounter: original, paid RX claims that: 1) can be found on an Eligible file enrollment time span segment, 2) can be found on an Eligible file eligibility determinant segment that spans the beginning date of service on the claims file, and 3) are limited to family planning benefits which also have a non-family planning program type	N/A
11/20/2025	4.0.22	ALL-13-002-2	UPDATE	Specification	STEP 1: Active non-duplicate RX records during DQ report monthDefine the RX 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 FFS and Encounter: Original, 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"2. ADJUSTMENT_IND = "0"STEP 3: Non-missing prescription fill dateOf the claims that meet the criteria from STEP 2, restrict to non-missing PRESCRIPTION-FILL-DATESTEP 4: Link claims to enrollment time spanKeep all claims from STEP 3 for which the MSIS ID on the claim is also found on an ENROLLMENT-TIME-SPAN-ELG00021 segmentSTEP 5: Family planning during date of serviceLink MSIS-IDs from the claims in STEP 4 to the ELIGIBILITY-DETERMINANTS-ELG00005 file segment and keep segments that satisfy the following criteria:1. PRIMARY-ELIGIBILITY-GROUP-IND = 12. RESTRICTED-BENEFIT-CODE = "6"3. Claims PRESCRIPTION-FILL-DATE >= ELIGIBILITY-DETERMINANT-EFF-DATE4. Claims PRESCRIPTION-FILL-DATE <= ELIGIBILITY-DETERMINANT-END-DATE OR ELIGIBILITY-DETERMINANT-END-DATE is missingSTEP 6: Unique MSIS-IDs in claimsOf the claims that meet the criteria from STEP 5, limit to unique MSIS-IDsSTEP 7: Non-family planning servicesOf the claims that meet the criteria from STEP 5, restrict to claims with:1a. PROGRAM-TYPE not equal to "2"OR1b. PROGRAM-TYPE is missingSTEP 8: Calculate percentageDivide the count of unique MSIS-IDs from STEP 7 by the count of MSIS-IDs from STEP 6	N/A
04/24/2025	4.0.7	ALL-13-002-2	ADD	N/A		Created