| 11/20/2025 |
4.0.22 |
ALL-19-001-1 |
UPDATE |
Specification |
STEP 1: Active non-duplicate OT records during DQ report monthDefine the OT claims universe at the line level by importing both headers and lines that satisfy the following criteria:For Headers:1. Reporting Period from 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.For Lines:1. Reporting Period from the filename = DQ report month2. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing3. 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-ADJUSTMENT-IND.4. Lines merge to a header using ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND=LINE-ADJUSTMENT-IND.STEP 2: Medicaid and S-CHIP FFS: Original and Adjustment, Paid ClaimsOf the claim lines that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "1" or "3" or "A" or "C"STEP 3: HCBS service under 1915(c) HCBS WaiverOf the claim lines that meet the criteria from STEP 2, restrict to: 1. HCBS-SERVICE-CODE = 4STEP 4: Missing WAIVER-IDOf the claim lines that meet the criteria from STEP 3, restrict to those that satisfy:1. WAIVER-ID is missing STEP 5: Calculate the percentage for the measureDivide the count of claim headers from STEP 4 by the count of claim headers from STEP 3 |
N/A |
| 08/13/2025 |
4.0.16 |
ALL-19-001-1 |
UPDATE |
Specification |
STEP 1: Active non-duplicate OT records during DQ report monthDefine the OT claims universe at the line level by importing both headers and lines that satisfy the following criteria:For Headers:1. Reporting Period from 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.For Lines:1. Reporting Period from the filename = DQ report month2. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing3. 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-ADJSTMT-IND.STEP 2: Medicaid and S-CHIP FFS: Original and Adjustment, Paid ClaimsOf the claim lines that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "1" or "3" or "A" or "C"STEP 3: HCBS service under 1915(c) HCBS WaiverOf the claim lines that meet the criteria from STEP 2, restrict to: 1. HCBS-SERVICE-CODE = 4STEP 4: Missing WAIVER-IDOf the claim lines that meet the criteria from STEP 3, restrict to those that satisfy:1. WAIVER-ID is missing STEP 5: Calculate the percentage for the measureDivide the count of claim headers from STEP 4 by the count of claim headers from STEP 3 |
STEP 1: Active non-duplicate OT records during DQ report monthDefine the OT claims universe at the line level by importing both headers and lines that satisfy the following criteria:For Headers:1. Reporting Period from 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.For Lines:1. Reporting Period from the filename = DQ report month2. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing3. 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-ADJUSTMENT-IND.4. Lines merge to a header using ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND=LINE-ADJUSTMENT-IND.STEP 2: Medicaid and S-CHIP FFS: Original and Adjustment, Paid ClaimsOf the claim lines that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "1" or "3" or "A" or "C"STEP 3: HCBS service under 1915(c) HCBS WaiverOf the claim lines that meet the criteria from STEP 2, restrict to: 1. HCBS-SERVICE-CODE = 4STEP 4: Missing WAIVER-IDOf the claim lines that meet the criteria from STEP 3, restrict to those that satisfy:1. WAIVER-ID is missing STEP 5: Calculate the percentage for the measureDivide the count of claim headers from STEP 4 by the count of claim headers from STEP 3 |
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