ALL-2-004-4

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TMSIS Dataguide

Medicaid.gov

Version:

ALL-2-004-4

Data Quality Measure

Last updated

Key Information

Measure Name	% of active 1915(i) MSIS IDs (STATE-PLAN-OPTION-TYPE = '02') during the reporting period with 1915(i) claim lines (HCBS-SERVICE-CODE = '1')
File Type	Multiple Files
Measure ID	ALL-2-004-4
Measure Type	Claims Percentage
Content area	ALL

Validation

Validation Type	Longitudinal and Inferential

Measure Priority

Measure Priority	High
Focus Area	N/A
Category	Program participation

Claim Information

Claim Type	Medicaid,FFS or Medicaid,Enc
Adjustment Type	Original
Crossover Type	Non-Crossover

Thresholds

Minimum	0.8
Maximum	1
TA Minimun	0.8
TA Maximum	1
Longitudinal Threshold	0.2
For TA (for including in compliance training)	TA- Inferential
For TA (Longitudinal)	No

Data Elements

DD Data Element	MSIS-IDENTIFICATION-NUM • HCBS-SERVICE-CODE • MSIS-IDENTIFICATION-NUM • STATE-PLAN-OPTION-TYPE
DD Data Element Number	COT157 • COT187 • ELG162 • ELG163

Annotation	N/A
Specification	N/A

Published Date	Data Guide Version	DQM	Action	Field	Before	After
11/20/2025	4.0.22	ALL-2-004-4	UPDATE	Annotation	The percentage of active 1915(i) eligibles (STATE-PLAN-OPTION-TYPE = '02') with Medicaid FFS and Encounter: original, non-crossover, paid OT claims that are 1915(i) claim records (HCBS-SERVICE-CODE = '1') during the reporting period	N/A
11/20/2025	4.0.22	ALL-2-004-4	UPDATE	Specification	STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: State plan participation on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 1, further refine the population using segment STATE-PLAN-OPTION-PARTICIPATION-ELG00011 by keeping records that satisfy the following criteria:1a. STATE-PLAN-OPTION-EFF-DATE <= last day of the DQ report month2a. STATE-PLAN-OPTION-END-DATE >= last day of the DQ report month OR missingOR1b. STATE-PLAN-OPTION-EFF-DATE is missing2b. STATE-PLAN-OPTION-END-DATE is missingSTEP 3: 1915(i) eligiblesOf the MSIS-IDs that meet the criteria from STEP 2, further refine the population by keeping records that satisfy the following criteria:STATE-PLAN-OPTION-TYPE = '02'STEP 4: Active non-duplicate paid OT claims during 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 5: Medicaid FFS and Encounter: Original, Non-Crossover, Paid ClaimsOf the claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "1" or "3" 2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "0" or is missingSTEP 6: HCBS under 1915(i)Of the claims from STEP 5, further restrict by the below criteria1. HCBS-SERVICE-CODE = "1"STEP 7: Eligibles with OT claimsOf the MSIS-IDs from STEP 3, count the number which also appear in the claims from STEP 6STEP 8: Calculate percentage for measureDivide the number of MSIS-IDs from STEP 7 by the number of MSIS-IDs from STEP 3	N/A
08/13/2025	4.0.16	ALL-2-004-4	UPDATE	Specification	STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: State plan participation on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 1, further refine the population using segment STATE-PLAN-OPTION-PARTICIPATION-ELG00011 by keeping records that satisfy the following criteria:1a. STATE-PLAN-OPTION-EFF-DATE <= last day of the DQ report month2a. STATE-PLAN-OPTION-END-DATE >= last day of the DQ report month OR missingOR1b. STATE-PLAN-OPTION-EFF-DATE is missing2b. STATE-PLAN-OPTION-END-DATE is missingSTEP 3: 1915(i) eligiblesOf the MSIS-IDs that meet the criteria from STEP 2, further refine the population by keeping records that satisfy the following criteria:STATE-PLAN-OPTION-TYPE = '02'STEP 4: Active non-duplicate paid OT claims during 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 5: Medicaid FFS and Encounter: Original, Non-Crossover, Paid ClaimsOf the claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "1" or "3" 2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "0" or is missingSTEP 6: HCBS under 1915(i)Of the claims from STEP 5, further restrict by the below criteria1. HCBS-SERVICE-CODE = "1"STEP 7: Eligibles with OT claimsOf the MSIS-IDs from STEP 3, count the number which also appear in the claims from STEP 6STEP 8: Calculate percentage for measureDivide the number of MSIS-IDs from STEP 7 by the number of MSIS-IDs from STEP 3	STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: State plan participation on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 1, further refine the population using segment STATE-PLAN-OPTION-PARTICIPATION-ELG00011 by keeping records that satisfy the following criteria:1a. STATE-PLAN-OPTION-EFF-DATE <= last day of the DQ report month2a. STATE-PLAN-OPTION-END-DATE >= last day of the DQ report month OR missingOR1b. STATE-PLAN-OPTION-EFF-DATE is missing2b. STATE-PLAN-OPTION-END-DATE is missingSTEP 3: 1915(i) eligiblesOf the MSIS-IDs that meet the criteria from STEP 2, further refine the population by keeping records that satisfy the following criteria:STATE-PLAN-OPTION-TYPE = '02'STEP 4: Active non-duplicate paid OT claims during 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 5: Medicaid FFS and Encounter: Original, Non-Crossover, Paid ClaimsOf the claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "1" or "3" 2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "0" or is missingSTEP 6: HCBS under 1915(i)Of the claims from STEP 5, further restrict by the below criteria1. HCBS-SERVICE-CODE = "1"STEP 7: Eligibles with OT claimsOf the MSIS-IDs from STEP 3, count the number which also appear in the claims from STEP 6STEP 8: Calculate percentage for measureDivide the number of MSIS-IDs from STEP 7 by the number of MSIS-IDs from STEP 3
04/24/2025	4.0.7	ALL-2-004-4	ADD	N/A		Created