ALL-4-003-3

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-4-003-3

Data Quality Measure

Last updated

Key Information

Measure Name	% of billing and servicing provider numbers on claims that are not found in the provider file
File Type	Multiple Files
Measure ID	ALL-4-003-3
Measure Type	Claims percentage
Content area	ALL MULTI PRO

Validation

Validation Type	Inferential

Measure Priority

Measure Priority	High
Focus Area	N/A
Category	Provider identifiers

Claim Information

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

Thresholds

Minimum	0
Maximum	0.1
TA Minimun	0
TA Maximum	0.1
Longitudinal Threshold	N/A
For TA (for including in compliance training)	TA- Inferential
For TA (Longitudinal)	No

Data Elements

DD Data Element	PROV-IDENTIFIER • SUBMITTING-STATE-PROV-ID • BILLING-PROV-NUM • SERVICING-PROV-NUM
DD Data Element Number	PRV081 • PRV019 • COT112 • COT189

Annotation	N/A
Specification	N/A

Published Date	Data Guide Version	DQM	Action	Field	Before	After
11/20/2025	4.0.22	ALL-4-003-3	UPDATE	Annotation	Percentage of unique state assigned provider IDs for billing and servicing provider on the OT file that do not match the provider IDs on the provider file	N/A
11/20/2025	4.0.22	ALL-4-003-3	UPDATE	Specification	STEP 1: Active non-duplicate OT records during DQ 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: Unique state-assigned provider IDsFor each of the OT claims identified in STEP 1, create a list of unique state-assigned provider IDs using the following data elements:1. BILLING-PROV-NUM2. SERVICING-PROV-NUMSTEP 3: Match state-assigned provider IDs to provider file IDsMatch the unique state assigned provider IDs identified in STEP 2 to the SUBMITTING-STATE-PROV-ID in the PROV-ATTRIBUTES-MAIN-PRV00002 segment OR the PROV-IDENTIFIER in the PROV-IDENTIFIERS-PRV00005 segmentSTEP 4: Number of non-matchesCount the number of unique state assigned provider IDs from STEP 2 that fail to match in STEP 3STEP 5: Percentage of non-matchesDivide the count from STEP 4 by the total number of unique state assigned provider IDs identified in STEP 2	N/A
08/13/2025	4.0.16	ALL-4-003-3	UPDATE	Specification	STEP 1: Active non-duplicate OT records during DQ 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: Unique state-assigned provider IDsFor each of the OT claims identified in STEP 1, create a list of unique state-assigned provider IDs using the following data elements:1. BILLING-PROV-NUM2. SERVICING-PROV-NUMSTEP 3: Match state-assigned provider IDs to provider file IDsMatch the unique state assigned provider IDs identified in STEP 2 to the SUBMITTING-STATE-PROV-ID in the PROV-ATTRIBUTES-MAIN-PRV00002 segment OR the PROV-IDENTIFIER in the PROV-IDENTIFIERS-PRV00005 segmentSTEP 4: Number of non-matchesCount the number of unique state assigned provider IDs from STEP 2 that fail to match in STEP 3STEP 5: Percentage of non-matchesDivide the count from STEP 4 by the total number of unique state assigned provider IDs identified in STEP 2	STEP 1: Active non-duplicate OT records during DQ 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: Unique state-assigned provider IDsFor each of the OT claims identified in STEP 1, create a list of unique state-assigned provider IDs using the following data elements:1. BILLING-PROV-NUM2. SERVICING-PROV-NUMSTEP 3: Match state-assigned provider IDs to provider file IDsMatch the unique state assigned provider IDs identified in STEP 2 to the SUBMITTING-STATE-PROV-ID in the PROV-ATTRIBUTES-MAIN-PRV00002 segment OR the PROV-IDENTIFIER in the PROV-IDENTIFIERS-PRV00005 segmentSTEP 4: Number of non-matchesCount the number of unique state assigned provider IDs from STEP 2 that fail to match in STEP 3STEP 5: Percentage of non-matchesDivide the count from STEP 4 by the total number of unique state assigned provider IDs identified in STEP 2
04/24/2025	4.0.7	ALL-4-003-3	ADD	N/A		Created