ALL-18-004-4

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Measure Name	# of claim headers with TYPE-OF-CLAIM = U, V, W, X or Y that aren’t MFP (PROGRAM-TYPE = 08)
File Type	CRX
Measure ID	ALL-18-004-4
Measure Type	Count
Content area	ALL

Validation Type	Inferential

Measure Priority	High
Focus Area	N/A
Category	Expenditures

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

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

DD Data Element	PROGRAM-TYPE • TYPE-OF-CLAIM
DD Data Element Number	CRX055 • CRX029

Annotation	N/A
Specification	N/A

Published Date	Data Guide Version	DQM	Action	Field	Before	After
11/20/2025	4.0.22	ALL-18-004-4	UPDATE	Annotation	Count the number of paid RX claim headers for TYPE-OF-CLAIM = U, V, W, X, Y that aren't MFP	N/A
11/20/2025	4.0.22	ALL-18-004-4	UPDATE	Specification	STEP 1: Active non-duplicate RX claims during DQ report monthDefine the RX claims 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: Count "other" claims that aren't MFPOf the claims that meet the criteria from STEP 1, count the number of claims that satisfy the following criteria:1. TYPE-OF-CLAIM = "U" or "V" or "W" or "X" or "Y"2. PROGRAM-TYPE is not equal to "08" or is missing	N/A
04/24/2025	4.0.7	ALL-18-004-4	ADD	N/A		Created

ALL-18-004-4

Key Information

Validation

Measure Priority

Claim Information

Thresholds

Data Elements