| 11/20/2025 |
4.0.22 |
ALL-35-004-4 |
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-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: Non-missing tooth numberOf the claims that meet criteria from STEP 2, keep those with non-missing TOOTH-NUM.STEP 4: Procedure code format does not indicate a CDT codeOf the claims that meet the criteria from STEP 3, keep those that do NOT meet following criteria:1. Length of PROCEDURE-CODE is 52. PROCEDURE-CODE begins with "D"3. PROCEDURE-CODE only contains digits 0-9 in positions 2-5STEP 5: Calculate percentageDivide the count of claim lines from STEP 4 by the count of claim lines from STEP 3 |
N/A |
| 08/13/2025 |
4.0.16 |
ALL-35-004-4 |
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: Non-missing tooth numberOf the claims that meet criteria from STEP 2, keep those with non-missing TOOTH-NUM.STEP 4: Procedure code format does not indicate a CDT codeOf the claims that meet the criteria from STEP 3, keep those that do NOT meet following criteria:1. Length of PROCEDURE-CODE is 52. PROCEDURE-CODE begins with "D"3. PROCEDURE-CODE only contains digits 0-9 in positions 2-5STEP 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: Non-missing tooth numberOf the claims that meet criteria from STEP 2, keep those with non-missing TOOTH-NUM.STEP 4: Procedure code format does not indicate a CDT codeOf the claims that meet the criteria from STEP 3, keep those that do NOT meet following criteria:1. Length of PROCEDURE-CODE is 52. PROCEDURE-CODE begins with "D"3. PROCEDURE-CODE only contains digits 0-9 in positions 2-5STEP 5: Calculate percentageDivide the count of claim lines from STEP 4 by the count of claim lines from STEP 3 |
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