| 08/13/2025 |
4.0.16 |
ALL-35-002-2 |
UPDATE |
Specification |
STEP 1: 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 2: S-CHIP FFS and Encounter: Original and Replacement Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "A" or "C"2. ADJUSTMENT-IND = "0" or "4"STEP 3: Tooth-related procedure codesOf the claims that meet criteria from STEP 2, keep those with a PROCEDURE-CODE that matches one of the following criteria:1. PROCEDURE-CODE = “D1351” or “D2140” or “D2150” or “D2160” or “D2161” or “D2330” or “D2331” or “D2332” or “D2335” or “D2390” or “D2391” or “D2392” or “D2393” or “D2394” or “D3230” or “D3240” or “D3310” or “D3320” or “D3330”STEP 4: Missing tooth numberOf the claims that meet criteria from STEP 3, keep those with a missing TOOTH-NUMSTEP 5: Calculate percentageDivide the count of claim lines from STEP 4 by the count of claim lines from STEP 3 |
STEP 1: 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 2: S-CHIP FFS and Encounter: Original and Replacement Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "A" or "C"2. ADJUSTMENT-IND = "0" or "4"STEP 3: Tooth-related procedure codesOf the claims that meet criteria from STEP 2, keep those with a PROCEDURE-CODE that matches one of the following criteria:1. PROCEDURE-CODE = “D1351” or “D2140” or “D2150” or “D2160” or “D2161” or “D2330” or “D2331” or “D2332” or “D2335” or “D2390” or “D2391” or “D2392” or “D2393” or “D2394” or “D3230” or “D3240” or “D3310” or “D3320” or “D3330”STEP 4: Missing tooth numberOf the claims that meet criteria from STEP 3, keep those with a missing TOOTH-NUMSTEP 5: Calculate percentageDivide the count of claim lines from STEP 4 by the count of claim lines from STEP 3 |
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