ALL-2-011-11

An official website of the United States government

Official websites use .gov
A .gov website belongs to an official government organization in the United States.

Secure .gov websites use HTTPS
A lock () or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites.

TMSIS Dataguide

Medicaid.gov

Version:

ALL-2-011-11

Data Quality Measure

Last updated

Key Information

Measure Name	% of 1915(c) waiver enrollees (WAIVER-TYPE = 06 - 20 or 33) that do not have any claim headers with HCBS-SERVICE-CODE = 4
File Type	Multiple Files
Measure ID	ALL-2-011-11
Measure Type	Claims Percentage
Content area	ELG ALL MULTI

Validation

Validation Type	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	All Indicators

Thresholds

Minimum	0
Maximum	0.5
TA Minimun	0
TA Maximum	0.5
Longitudinal Threshold	N/A
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 • WAIVER-TYPE
DD Data Element Number	ELG171 • COT187 • COT022 • ELG173

Annotation

Calculate the percentage of eligibles enrolled in a 1915(c) waiver that do not have Medicaid FFS and Encounter, original paid OT claims with the corresponding HCBS service code

Specification

STEP 1: Enrolled on the last day of DQ report month

Define 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 missing

3. MSIS-IDENTIFICATION-NUM is not missing

STEP 2: Waiver participation on the last day of DQ report month

Of the MSIS-IDs that meet the criteria from STEP 1, further refine the population using segment WAIVER-PARTICIPATION-ELG00012 by keeping records that satisfy the following criteria:

1a. WAIVER-ENROLLMENT-EFF-DATE <= last day of the DQ report month

2a. WAIVER-ENROLLMENT-END-DATE >= last day of the DQ report month OR missing

OR

1b. WAIVER-ENROLLMENT-EFF-DATE is missing

2b. WAIVER-ENROLLMENT-END-DATE is missing

STEP 3: Enrollment in 1915(c) waiver

Of the MSIS IDs that meet the criteria for STEP 2, further refine the population to MSIS IDs where WAIVER-TYPE-CODE = ("06" - "20", "33")

STEP 4: Active non-duplicate paid OT claims during report month

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

For Headers:

1. Reporting Period from the filename = DQ report month

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

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

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

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

6. 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 month

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

3. 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, Paid Claims

Of 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"

STEP 6: Link MSIS IDs from EL to OT

Retain the MSIS IDs from STEP 3 that link to an OT claim from STEP 5

STEP 7: Service under 1915(c) HCBS waiver

Retain the MSIS IDs from STEP 6 where the HCBS-SERVICE-CODE = "4"

STEP 8: MSIS IDs without service under 1915(c) HCBS waiver

Subtract the number of unique MSIS IDs in STEP 7 from the number of unique MSIS IDs in STEP 3

STEP 9: Calculate percentage

Divide the count of unique MSIS IDs in STEP 8 by the count of unique MSIS IDs in STEP 3

Published Date	Data Guide Version	DQM	Action	Field	Before	After
08/13/2025	4.0.16	ALL-2-011-11	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: Waiver 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 WAIVER-PARTICIPATION-ELG00012 by keeping records that satisfy the following criteria:1a. WAIVER-ENROLLMENT-EFF-DATE <= last day of the DQ report month2a. WAIVER-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. WAIVER-ENROLLMENT-EFF-DATE is missing2b. WAIVER-ENROLLMENT-END-DATE is missingSTEP 3: Enrollment in 1915(c) waiverOf the MSIS IDs that meet the criteria for STEP 2, further refine the population to MSIS IDs where WAIVER-TYPE-CODE = ("06" - "20", "33")STEP 4: Active non-duplicate paid OT claims during report monthDefine the OT claims universe at the header 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, 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"STEP 6: Link MSIS IDs from EL to OTRetain the MSIS IDs from STEP 3 that link to an OT claim from STEP 5STEP 7: Service under 1915(c) HCBS waiverRetain the MSIS IDs from STEP 6 where the HCBS-SERVICE-CODE = "4"STEP 8: MSIS IDs without service under 1915(c) HCBS waiverSubtract the number of unique MSIS IDs in STEP 7 from the number of unique MSIS IDs in STEP 3STEP 9: Calculate percentageDivide the count of unique MSIS IDs in STEP 8 by the count of unique MSIS IDs in 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: Waiver 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 WAIVER-PARTICIPATION-ELG00012 by keeping records that satisfy the following criteria:1a. WAIVER-ENROLLMENT-EFF-DATE <= last day of the DQ report month2a. WAIVER-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. WAIVER-ENROLLMENT-EFF-DATE is missing2b. WAIVER-ENROLLMENT-END-DATE is missingSTEP 3: Enrollment in 1915(c) waiverOf the MSIS IDs that meet the criteria for STEP 2, further refine the population to MSIS IDs where WAIVER-TYPE-CODE = ("06" - "20", "33")STEP 4: Active non-duplicate paid OT claims during report monthDefine the OT claims universe at the header 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, 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"STEP 6: Link MSIS IDs from EL to OTRetain the MSIS IDs from STEP 3 that link to an OT claim from STEP 5STEP 7: Service under 1915(c) HCBS waiverRetain the MSIS IDs from STEP 6 where the HCBS-SERVICE-CODE = "4"STEP 8: MSIS IDs without service under 1915(c) HCBS waiverSubtract the number of unique MSIS IDs in STEP 7 from the number of unique MSIS IDs in STEP 3STEP 9: Calculate percentageDivide the count of unique MSIS IDs in STEP 8 by the count of unique MSIS IDs in STEP 3
04/24/2025	4.0.7	ALL-2-011-11	ADD	N/A		Created