ALL-13-003-5

Data Quality Measure

Last updated

Key Information

Measure Name	% of MSIS IDs with alien restricted benefits code status (RESTRICTED-BENEFITS-CODE = 2) with services that are not emergency room or pregnancy-related
File Type	Multiple Files
Measure ID	ALL-13-003-5
Measure Type	Claims Percentage
Content area	ALL

Validation

Validation Type	Inferential

Measure Priority

Measure Priority	Medium
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	ADMISSION-DATE • ELIGIBILITY-DETERMINANT-EFF-DATE • ELIGIBILITY-DETERMINANT-END-DATE • PROCEDURE-CODE-1 • RESTRICTED-BENEFITS-CODE • MSIS-IDENTIFICATION-NUM • DIAGNOSIS-CODE • REVENUE-CODE • PROCEDURE-CODE-2 • PROCEDURE-CODE-6 • MSIS-IDENTIFICATION-NUM
DD Data Element Number	CIP094 • ELG099 • ELG100 • CIP070 • ELG097 • ELG251 • CIP332 • CIP245 • CIP074 • CIP090 • CIP022

Annotation	The percentage of MSIS IDs with a restricted benefits code of 2 (alien status) that have Medicaid FFS and Encounter: original, paid IP claims that are not emergency room or pregnancy-related services
Specification	STEP 1: Active non-duplicate IP records during DQ report month Define the IP records universe at the header level by importing headers, lines, and DX segments that satisfy the following criteria: For Headers: 1. Reporting Period from 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. For Lines: 1. Reporting Period from the filename = DQ report month 2. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing 3. No Line Duplicates: Duplicates are dropped at the line level if the following data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, LINE-NUM-ORIG, LINE-NUM-ADJ, and LINE-ADJSTMT-IND. 4. Lines merge to a header using ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND=LINE-ADJUSTMENT-IND. For DX segments: 1. DX segments merge to a header using ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND. 2. No DX Duplicates: Duplicates are dropped at the diagnosis level, if the following seven data elements are the same: SUBMITTING-STATE, ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, ADJUSTMENT-IND, DIAGNOSIS-TYPE-CODE, and DIAGNOSIS-SEQUENCE-NUMBER. STEP 2: Medicaid FFS and 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 = "1" or "3" 2. ADJUSTMENT_IND = "0" STEP 3: Non-missing admission date Of the claims that meet the criteria from STEP 2, restrict to non-missing ADMISSION-DATE STEP 4: Link claims to enrollment time span Keep all claims from STEP 3 for which the MSIS ID on the claim is also found on an ENROLLMENT-TIME-SPAN-ELG00021 segment STEP 5: Alien during date of service Link 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 = 1 2. RESTRICTED-BENEFIT-CODE = "2" 3. Claims ADMISSION-DATE>= ELIGIBILITY-DETERMINANT-EFF-DATE 4. Claims ADMISSION-DATE <= ELIGIBILITY-DETERMINANT-END-DATE OR ELIGIBILITY-DETERMINANT-END-DATE is missing STEP 6: Unique MSIS-IDs in claims Of the claims that meet the criteria from STEP 5, limit to unique MSIS-IDs STEP 7: Non-emergency room and non-pregnancy related services Of the claims that meet the criteria from STEP 5, restrict to claims that do NOT have emergency room revenue codes or pregnancy-related diagnosis codes or procedure codes: NOT (1a. REVENUE-CODE equal to ("450", "451", "452", "453", "454", "455", "456", "457", "458", "459", "0450", "0451", "0452", "0453", "0454", "0455", "0456", "0457", "0458", "0459" ,“0981”,“0720”, “0721”, “0722”, “0723”, “0724”, “0729”) OR 2a. PROCEDURE-CODE-1 through PROCEDURE-CODE-6 is found in the Pregnancy CodeSet tab for ICD-10-PCM code types) OR 2a. has any DX segment where DIAGNOSIS-CODE is found in the Pregnancy CodeSet tab for ICD-10-CM code types STEP 8: Calculate percentage Divide the count of unique MSIS-IDs from STEP 7 by the count of MSIS-IDs from STEP 6.

Annotation

The percentage of MSIS IDs with a restricted benefits code of 2 (alien status) that have Medicaid FFS and Encounter: original, paid IP claims that are not emergency room or pregnancy-related services

Specification

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

Define the IP records universe at the header level by importing headers, lines, and DX segments that satisfy the following criteria:

For Headers:

1. Reporting Period from 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.

For Lines:

1. Reporting Period from the filename = DQ report month

2. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing

3. No Line Duplicates: Duplicates are dropped at the line level if the following data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, LINE-NUM-ORIG, LINE-NUM-ADJ, and LINE-ADJSTMT-IND.

4. Lines merge to a header using ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND=LINE-ADJUSTMENT-IND.

For DX segments:

1. DX segments merge to a header using ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND.

2. No DX Duplicates: Duplicates are dropped at the diagnosis level, if the following seven data elements are the same: SUBMITTING-STATE, ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, ADJUSTMENT-IND, DIAGNOSIS-TYPE-CODE, and DIAGNOSIS-SEQUENCE-NUMBER.

STEP 2: Medicaid FFS and 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 = "1" or "3"

2. ADJUSTMENT_IND = "0"

STEP 3: Non-missing admission date

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

STEP 4: Link claims to enrollment time span

Keep all claims from STEP 3 for which the MSIS ID on the claim is also found on an ENROLLMENT-TIME-SPAN-ELG00021 segment

STEP 5: Alien during date of service

Link 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 = 1

2. RESTRICTED-BENEFIT-CODE = "2"

3. Claims ADMISSION-DATE>= ELIGIBILITY-DETERMINANT-EFF-DATE

4. Claims ADMISSION-DATE <= ELIGIBILITY-DETERMINANT-END-DATE OR ELIGIBILITY-DETERMINANT-END-DATE is missing

STEP 6: Unique MSIS-IDs in claims

Of the claims that meet the criteria from STEP 5, limit to unique MSIS-IDs

STEP 7: Non-emergency room and non-pregnancy related services

Of the claims that meet the criteria from STEP 5, restrict to claims that do NOT have emergency room revenue codes or pregnancy-related diagnosis codes or procedure codes:

NOT

(1a. REVENUE-CODE equal to ("450", "451", "452", "453", "454", "455", "456", "457", "458", "459", "0450", "0451", "0452", "0453", "0454", "0455", "0456", "0457", "0458", "0459" ,“0981”,“0720”, “0721”, “0722”, “0723”, “0724”, “0729”)

OR

2a. PROCEDURE-CODE-1 through PROCEDURE-CODE-6 is found in the Pregnancy CodeSet tab for ICD-10-PCM code types)

OR

2a. has any DX segment where DIAGNOSIS-CODE is found in the Pregnancy CodeSet tab for ICD-10-CM code types

STEP 8: Calculate percentage

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