ALL-21-001-1

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Measure Name	% of BILLING-PROV-NUM on claim headers that do not have a match in PRV00007 with active provider enrollment status (PROV-MEDICAID-ENROLLMENT-STATUS-CODE in (1, 2, 3, 4, 5, 6) on Admission Date
File Type	Multiple Files
Measure ID	ALL-21-001-1
Measure Type	Claims Percentage
Content area	ALL MULTI PRO

Validation Type	Inferential

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

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

Minimum	0
Maximum	0.05
TA Minimun
TA Maximum
Longitudinal Threshold	N/A
For TA (for including in compliance training)	No
For TA (Longitudinal)	No

DD Data Element	ADMISSION-DATE • PROV-MEDICAID-EFF-DATE • PROV-MEDICAID-END-DATE • SUBMITTING-STATE-PROV-ID • PROV-MEDICAID-ENROLLMENT-STATUS-CODE • BILLING-PROV-NUM
DD Data Element Number	CIP094 • PRV098 • PRV099 • PRV097 • PRV100 • CIP179

Annotation	N/A
Specification	N/A

Published Date	Data Guide Version	DQM	Action	Field	Before	After
11/20/2025	4.0.22	ALL-21-001-1	UPDATE	Annotation	Calculate the percentage of unique billing provider numbers on Medicaid and S-CHIP FFS and Encounter: original and adjustment, paid IP claims that do not have an active record indicating they are a Medicaid-enrolled provider on a claim admission date	N/A
11/20/2025	4.0.22	ALL-21-001-1	UPDATE	Specification	STEP 1: Active non-duplicate paid IP claims during report monthDefine the IP claims universe at the header level that satisfy the following criteria: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.STEP 2: Medicaid and S-CHIP FFS and Encounter: Original and Adjustment, Paid ClaimsOf the claims 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: Unique billing provider numbers on the claimsFrom the claims that meet the criteria from STEP 2, create a list of unique BILLING-PROV-NUM values where:1. BILLING-PROV-NUM is not missingSTEP 4: Providers without enrollment on the claim admission dateOf the unique provider identifiers from STEP 3, refine the list using PROV-MEDICAID-ENROLLMENT-PRV00007 by keeping providers that do not meet all of the following criteria for all claims:1. BILLING-PROV-NUM found in SUBMITTING-STATE-PROV-ID2. PROV-MEDICAID-ENROLLMENT-STATUS-CODE = ("1" or "01") or ("2" or "02") or ("3" or "03") or ("4" or "04") or ("5" or "05") or ("6" or "06")3. ADMISSION-DATE from the claim is greater than or equal to PROV-MEDICAID-EFF-DATE4a. ADMISSION-DATE from the claim is less than or equal to PROV-MEDICAID-END-DATEOR4b. PROV-MEDICAID-END-DATE is missingSTEP 5: Calculate percentageDivide the count of unique providers from STEP 4 by the count from STEP 3	N/A
04/24/2025	4.0.7	ALL-21-001-1	ADD	N/A		Created

ALL-21-001-1

Key Information

Validation

Measure Priority

Claim Information

Thresholds

Data Elements