ALL-17-004-4

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TMSIS Dataguide

Medicaid.gov

Version:

ALL-17-004-4

Data Quality Measure

Last updated

Key Information

Measure Name	% of claim headers that have no corresponding claim lines
File Type	CRX
Measure ID	ALL-17-004-4
Measure Type	Claims Percentage
Content area	ALL

Validation

Validation Type	Inferential

Measure Priority

Measure Priority	N/A
Focus Area	N/A
Category	N/A

Claim Information

Claim Type	Medicaid,FFS or Medicaid,Cap or Medicaid,Enc or Medicaid,Serv or Medicaid,Supp or CHIP,FFS or CHIP,Cap or CHIP,Enc or CHIP,Serv or CHIP,Supp
Adjustment Type	All Adjustment Types
Crossover Type	All Indicators

Thresholds

Minimum	0
Maximum	0.001
TA Minimun
TA Maximum
Longitudinal Threshold	N/A
For TA (for including in compliance training)	No
For TA (Longitudinal)	No

Data Elements

DD Data Element
DD Data Element Number

Annotation

Calculate the percentage of paid RX claim headers that do not have corresponding claim lines

Specification

STEP 1: Active paid RX claims during DQ report month

Define the RX claims universe at the header level by importing both headers and lines that satisfy the following criteria:

1a. Limit to Report Month

Reporting Period from the filename = DQ report month

1b. Join Headers and Lines

Merge headers and lines using: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND=LINE-ADJUSTMENT-IND, and keep all claims, even if there is no match

1c. Keep headers and associated lines if header is not denied

1. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing

2. CLAIM-DENIED-INDICATOR is not equal to "0" or is missing

3. TYPE-OF-CLAIM is not equal to "Z" or is missing

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

1d. Drop 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.

1e. Keep line if line is not denied

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

STEP 2: Childless headers

Of the claim headers that meet the criteria from STEP 1, keep claim headers that did not merge to any claim line

STEP 3: Calculate percentage

Divide the count of claim headers from STEP 2 by the count of claim headers from STEP 1

Published Date	Data Guide Version	DQM	Action	Field	Before	After
08/13/2025	4.0.16	ALL-17-004-4	UPDATE	Specification	STEP 1: Active paid RX claims during DQ report monthDefine the RX claims universe at the header level by importing both headers and lines that satisfy the following criteria:1a. Limit to Report MonthReporting Period from the filename = DQ report month1b. Join Headers and LinesMerge headers and lines using: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND=LINE-ADJSTMT-IND, and keep all claims, even if there is no match1c. Keep headers and associated lines if header is not denied1. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing2. CLAIM-DENIED-INDICATOR is not equal to "0" or is missing3. TYPE-OF-CLAIM is not equal to "Z" or is missing4. CLAIM-STATUS is not equal to ("26","026","87","087","542","585", "654") or is missing1d. Drop Header DuplicatesDuplicates are dropped at the header level, if the following four data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND.1e. Keep line if line is not denied1. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missingSTEP 2: Childless headersOf the claim headers that meet the criteria from STEP 1, keep claim headers that did not merge to any claim lineSTEP 3: Calculate percentageDivide the count of claim headers from STEP 2 by the count of claim headers from STEP 1	STEP 1: Active paid RX claims during DQ report monthDefine the RX claims universe at the header level by importing both headers and lines that satisfy the following criteria:1a. Limit to Report MonthReporting Period from the filename = DQ report month1b. Join Headers and LinesMerge headers and lines using: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND=LINE-ADJUSTMENT-IND, and keep all claims, even if there is no match1c. Keep headers and associated lines if header is not denied1. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing2. CLAIM-DENIED-INDICATOR is not equal to "0" or is missing3. TYPE-OF-CLAIM is not equal to "Z" or is missing4. CLAIM-STATUS is not equal to ("26","026","87","087","542","585", "654") or is missing1d. Drop Header DuplicatesDuplicates are dropped at the header level, if the following four data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND.1e. Keep line if line is not denied1. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missingSTEP 2: Childless headersOf the claim headers that meet the criteria from STEP 1, keep claim headers that did not merge to any claim lineSTEP 3: Calculate percentageDivide the count of claim headers from STEP 2 by the count of claim headers from STEP 1
04/24/2025	4.0.7	ALL-17-004-4	ADD	N/A		Created