ALL-14-003-3

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TMSIS Dataguide

Medicaid.gov

Version:

ALL-14-003-3

Data Quality Measure

Last updated

Key Information

Measure Name	% of MSIS IDs on crossover claim headers not enrolled as duals (QMB, QMB Plus, SLMB Plus, Other) on Beginning Date of Service
File Type	Multiple Files
Measure ID	ALL-14-003-3
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	All Adjustment Types
Crossover Type	Crossover

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	ELIGIBILITY-DETERMINANT-EFF-DATE • ELIGIBILITY-DETERMINANT-END-DATE • BEGINNING-DATE-OF-SERVICE • MSIS-IDENTIFICATION-NUM • MSIS-IDENTIFICATION-NUM • DUAL-ELIGIBLE-CODE
DD Data Element Number	ELG099 • ELG100 • COT033 • ELG251 • COT022 • ELG085

Annotation	N/A
Specification	N/A

Published Date	Data Guide Version	DQM	Action	Field	Before	After
11/20/2025	4.0.22	ALL-14-003-3	UPDATE	Annotation	Calculate the percentage of MSIS IDs on Medicaid FFS and Encounter: original and adjustment, crossover paid OT 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 service date on the claims file, and 3) are not enrolled as duals	N/A
11/20/2025	4.0.22	ALL-14-003-3	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 FFS and Encounter: Original and Adjustment, 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" 2. CROSSOVER-IND = "1"STEP 3: Non-missing beginning service dateOf the claims that meet the criteria from STEP 2, restrict to non-missing BEGINNING-DATE-OF-SERVICESTEP 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 ENROLLEMENT-TIME-SPAN-ELG00021 segmentSTEP 5: Eligible during service dateLink 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. DUAL-ELIGIBLE-CODE not equal to (“01” or “02” or “04” or “08”) or is missing3. Claims BEGINNING-DATE-OF-SERVICE >= ELIGIBILITY-DETERMINANT-EFF-DATE 4. Claims BEGINNING-DATE-OF-SERVICE <= 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: Calculate percentageDivide the count of MSIS-IDs from STEP 6 by the count of MSIS-IDs in STEP 3	N/A
04/24/2025	4.0.7	ALL-14-003-3	ADD	N/A		Created