| 11/20/2025 |
4.0.22 |
ALL-21-005-5 |
UPDATE |
Specification |
STEP 1: Active non-duplicate paid IP claims during report monthDefine the IP 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 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 servicing provider numbers on the claim linesFrom the claim lines that meet the criteria from STEP 2, create a list of unique SERVICING-PROV-NUM values where:1. SERVICING-PROV-NUM is not missingSTEP 4: Providers without enrollment on the date of serviceOf 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. SERVICING-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. BEGINNING-DATE-OF-SERVICE from the claim line is greater than or equal to PROV-MEDICAID-EFF-DATE4a. BEGINNING-DATE-OF-SERVICE from the claim line 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 |
| 08/13/2025 |
4.0.16 |
ALL-21-005-5 |
UPDATE |
Specification |
STEP 1: Active non-duplicate paid IP claims during report monthDefine the IP 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 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 servicing provider numbers on the claim linesFrom the claim lines that meet the criteria from STEP 2, create a list of unique SERVICING-PROV-NUM values where:1. SERVICING-PROV-NUM is not missingSTEP 4: Providers without enrollment on the date of serviceOf 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. SERVICING-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. BEGINNING-DATE-OF-SERVICE from the claim line is greater than or equal to PROV-MEDICAID-EFF-DATE4a. BEGINNING-DATE-OF-SERVICE from the claim line 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 |
STEP 1: Active non-duplicate paid IP claims during report monthDefine the IP 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 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 servicing provider numbers on the claim linesFrom the claim lines that meet the criteria from STEP 2, create a list of unique SERVICING-PROV-NUM values where:1. SERVICING-PROV-NUM is not missingSTEP 4: Providers without enrollment on the date of serviceOf 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. SERVICING-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. BEGINNING-DATE-OF-SERVICE from the claim line is greater than or equal to PROV-MEDICAID-EFF-DATE4a. BEGINNING-DATE-OF-SERVICE from the claim line 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 |
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