EL-8-002-2

Data Quality Measure

Last updated

Key Information

Measure Name	Enrollment, capitation payments, capitation ratios, encounters (by claim file type) and encounter ratios (by claim file type) by plan ID with plan ID linking to MC file
File Type	Multiple Files
Measure ID	EL-8-002-2
Measure Type	Data Profile
Content area	ELG MCR MULTI EXP

Validation

Validation Type	Data Profile

Measure Priority

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

Claim Information

Claim Type	N/A
Adjustment Type	N/A
Crossover Type	N/A

Thresholds

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

Data Elements

DD Data Element	STATE-PLAN-ID-NUM • MANAGED-CARE-PLAN-TYPE • TYPE-OF-SERVICE • PLAN-ID-NUMBER • MANAGED-CARE-PLAN-TYPE • MANAGED-CARE-PLAN-ID • PLAN-ID-NUMBER • PLAN-ID-NUMBER • PLAN-ID-NUMBER • OFFSET-TRANS-TYPE • PAYEE-MCR-PLAN-TYPE • PAYMENT-OR-RECOUPMENT-AMOUNT • PAYMENT-AMOUNT • PAYEE-ID-TYPE • MBESCBES-FORM-GROUP • PAYMENT-OR-RECOUPMENT-AMOUNT
DD Data Element Number	MCR019 • ELG193 • COT186 • CLT080 • MCR024 • ELG192 • CIP130 • CRX056 • COT066 • FTX184 • FTX036 • FTX157 • FTX072 • FTX034 • FTX048 • FTX025

Annotation	For each unique plan id in the Eligible, Managed Care, Claims, or FTX files, pull associated plan type from Eligible and Managed Care Plan files and count the number of unique managed care enrollees, capitation payments, capitation ratios, encounters, and encounter ratios for the month referenced.
Specification	STEP 1: Enrolled on the last day of DQ report month Define the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria: 1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing 3. MSIS-IDENTIFICATION-NUM is not missing STEP 2: Managed care enrollment on the last day of DQ report month Of the MSIS-IDs that meet the criteria from STEP 1, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria: 1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month 2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missing OR 1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing 2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missing STEP 3: Managed care plans on the last day of DQ report month Define the managed care plan population from segment MANAGED-CARE-MAIN-MCR00002 by keeping active records that satisfy the following criteria: 1. MANAGED-CARE-MAIN-REC-EFF-DATE <= last day of the reporting month 2. MANAGED-CARE-MAIN-REC-END-DATE >= last day of the reporting month OR missing STEP 4: Active non-duplicate claims records during DQ report month Define the claims universe for IP, LT, and RX at the header level and for OT at the line level by importing headers (and lines for OT) that satisfy the following criteria: For Headers: 1. Reporting Period from the filename = DQ report month 2. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing 3. CLAIM-DENIED-INDICATOR is not equal to "0" or is missing 4. TYPE-OF-CLAIM is not equal to "Z" or is missing 5. CLAIM-STATUS is not equal to ("26","026","87","087","542","585", "654") or is missing 6. 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 month 2. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing 3. 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, and ADJUDICATION-DATE and ADJUSTMENT-IND=LINE-ADJUSTMENT-IND. STEP 5: Medicaid and S-CHIP Encounter: Paid Claims Of the claims that meet the criteria from STEP 4, further restrict them by the following criteria: 1. TYPE-OF-CLAIM = ("3" or "C") STEP 6: Capitation payment financial transactions: Define the FTX universe for the FTX0002, FTX0003, and FTX0005 tables respectively by keeping active records that satisfy the following criteria: 1. Reporting Period from the filename = DQ report month 2. No Duplicates: Duplicates are dropped at the table level, if the following four data elements are the same: ICN-ORIG, ICN-ADJ, PAYMENT-DATE or PAYMENT-OR-RECOUPMENT-DATE, and ADJUSTMENT-IND. STEP 7: Medicaid & S-CHIP Capitation Payment Of the financial transactions that meet the criteria from STEP 6, further restrict them by the following criteria: 1. PAYEE-ID-TYPE = ("02" or "05" or "06") For those in FTX0005 only: 1. OFFSET-TRANS-TYPE = "1" or "2" STEP 8: Define Plan_Id Define Plan_Id as a unique list of: MANAGED-CARE-PLAN-ID from the EL file that meet the constraints in STEP 2, STATE-PLAN-ID-NUM from the MCR file that meet the constraints in STEP 3, PLAN-ID-NUMBER from the claims files that meet the constraints in STEP 5, and PAYEE-ID from records that meet constraints in STEP 7. Also, define a blank Plan_Id for missing. STEP 9: Define Plan_Type_El In cases where Plan_Id can be linked to a MANAGED-CARE-PLAN-ID in MANAGED-CARE-PARTICIPATION-ELG00014, and there is only one plan type for that plan, define Plan_Type_El as MANAGED-CARE-PLAN-TYPE. If there are multiple plan types for the Plan_Id, then set Plan_Type_El to the most frequently used plan type, or the lowest plan type if there is a tie. (If there are multiple plan types, also set MultiplePlanTypes_EL = 1.) In all other cases, Plan_Type_El = missing. STEP 10: Define Plan_Type_Mc and Linked In cases where Plan_Id can be linked to a STATE-PLAN-ID-NUM in MANAGED-CARE-MAIN-MCR00002, set In_MCR_File = "Yes". If there is only one plan type for that plan, define Plan_Type_Mc as MANAGED-CARE-PLAN-TYPE . If there are multiple plan types for the Plan_Id, then set Plan_Type_Mc to the most frequently used plan type, or the lowest plan type if there is a tie. (If there are multiple plan types, also set MultiplePlanTypes_Mc = 1.) In all other cases, Plan_Type_Mc = missing and In_MCR_File = "No". STEP 11: Count Enrollment For each Plan_Id, define Enrollment as the count of unique MSIS-IDENTIFICATION-NUM that satisfy the constraints in STEP 2a STEP 12: Capitation Records For each record that meets the criteria from STEP 7, further restrict them by the following criteria: 1. ADJUSTMENT_IND = 0 2a. PAYMENT_OR_RECOUPMENT_AMOUNT (FTX00002 and FTX00005) > 0 OR 2b. PAYMENT_AMOUNT (FTX00003) > 0 STEP 13: Set Capitation Type Using the records in STEP 12: 1a. Set Capitation_Type = “Medicaid and S-CHIP” if at least one record with MBESCBES_FORM_GROUP = "1" OR "2" AND at least one record with MBESCBES_FORM_GROUP = "3" 1b. Set Capitation_Type = “Medicaid” if at least one record with MBESCBES_FORM_GROUP = "1" OR "2" AND no records with MBESCBES_FORM_GROUP = "3" 1c. Set Capitation_Type = "S-CHIP" if no records with MBESCBES_FORM_GROUP = "1" OR "2" AND at least one record with MBESCBES_FORM_GROUP = "3" STEP 14: Count Capitation_Hmo_Hio_Pace Define Capitation_Hmo_Hio_Pace as the count of unique FTX00002 records from STEP 12 that also satisfy the following criteria: 1. PAYEE-MCR-PLAN-TYPE = (“01” or “04” or “17”) STEP 15: Count Capitation_Php Define Capitation_Php as the count of unique FTX00002 records from STEP 12 that also satisfy the following criteria: 1. PAYEE-MCR-PLAN-TYPE = (“05” or “06”or “07”or “08”or “09” or “10” or “11”or “12” or “13”or “14” or “15”or “16” or “18”or “19”) STEP 16: Count Capitation_Pccm Define Capitation_Pccm as the count of unique FTX00002 records from STEP 12 that also satisfy the following criteria: 1. PAYEE-MCR-PLAN-TYPE = (“02" or "03") STEP 17: Count Capitation_Phi Define Capitation_Phi as the count of unique FTX00003 and FTX00005 records from STEP 12 that also satisfy the following criteria: 1. For FTX00005 records only, OFFSET-TRANS-TYPE = "2" STEP 18: Count Capitation_Other Define Capitation_Other as the count of unique FTX00002 and FTX00005 records from STEP 12 that also satisfy the following criteria: 1. PAYEE-MCR-PLAN-TYPE is not equal to (“01”,“02”,“03”,“04”, “05”,“06”,“07”,“08”,“09”,“10”,“11”,“12”,“13”,“14”,“15”,“16”, “17”,“18”,“19”) 2. For FTX00005 records only, OFFSET-TRANS-TYPE = "1" STEP 19: Count Capitation_Total Define Capitation_Total as the sum of Capitation_Hmo_Hio_Pace, Capitation_Php, Capitation_Pccm, Capitation_Phi, and Capitation_Other STEP 20: Encounter Claims Select encounter claims in the IP, LT, OT, and RX files by the following criteria: 1. PLAN-ID-NUMBER = Plan_Id 2. TYPE-OF-CLAIM = (“3” or “C”) 3. ADJUSTMENT-IND = “0” STEP 21: Set Encounter Type Using the records in STEP 20: 1a. Set Encounter_Type = “Medicaid and S-CHIP” if at least one record with TYPE-OF-CLAIM = “3” AND at least one record with TYPE-OF-CLAIM = “C” 1b. Set Encounter_Type = “Medicaid” if at least one record with TYPE-OF-CLAIM = “3” AND no records with TYPE-OF-CLAIM = “C” 1c. Set Encounter_Type = "S-CHIP" if no records with TYPE-OF-CLAIM = “3” AND at least one record with TYPE-OF-CLAIM = “C” STEP 22: Count Encounters_Ip Define Encounters_Ip as the count of unique IP header records from STEP 20 STEP 23: Count Encounters_Lt Define Encounters_Lt as the count of unique LT header records from STEP 20 STEP 24: Count Encounters_Ot Define Encounters_Ot as the count of unique OT line records from STEP 20 STEP 25: Count Encounters_Rx Define Encounters_Rx as the count of unique RX header records from STEP 20 STEP 26: Count Encounters_Total Define Encounters_Total as the sum of Encounters_Ip, Encounters_Lt, Encounters_Ot, and Encounters_Rx STEP 27: Count Ratios SET Capitation_Ratio = Capitation_Total / Enrollment SET Encounters_Ip_Ratio = Encounters_Ip / Enrollment SET Encounters_Lt_Ratio = Encounters_Lt / Enrollment SET Encounters_Ot_Ratio = Encounters_Ot / Enrollment SET Encounters_Rx_Ratio = Encounters_Rx / Enrollment STEP 28: Repeat for each Plan_Id REPEAT STEPS 9-27 for each Plan_Id identified in STEP 8

Annotation

For each unique plan id in the Eligible, Managed Care, Claims, or FTX files, pull associated plan type from Eligible and Managed Care Plan files and count the number of unique managed care enrollees, capitation payments, capitation ratios, encounters, and encounter ratios for the month referenced.

Specification

STEP 1: Enrolled on the last day of DQ report month

Define the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:

1. ENROLLMENT-EFF-DATE <= last day of the DQ report month

2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing

3. MSIS-IDENTIFICATION-NUM is not missing

STEP 2: Managed care enrollment on the last day of DQ report month

Of the MSIS-IDs that meet the criteria from STEP 1, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:

1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month

2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missing

OR

1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing

2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missing

STEP 3: Managed care plans on the last day of DQ report month

Define the managed care plan population from segment MANAGED-CARE-MAIN-MCR00002 by keeping active records that satisfy the following criteria:

1. MANAGED-CARE-MAIN-REC-EFF-DATE <= last day of the reporting month

2. MANAGED-CARE-MAIN-REC-END-DATE >= last day of the reporting month OR missing

STEP 4: Active non-duplicate claims records during DQ report month

Define the claims universe for IP, LT, and RX at the header level and for OT at the line level by importing headers (and lines for OT) that satisfy the following criteria:

For Headers:

1. Reporting Period from the filename = DQ report month

2. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing

3. CLAIM-DENIED-INDICATOR is not equal to "0" or is missing

4. TYPE-OF-CLAIM is not equal to "Z" or is missing

5. CLAIM-STATUS is not equal to ("26","026","87","087","542","585", "654") or is missing

6. 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 month

2. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing

3. 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, and ADJUDICATION-DATE and ADJUSTMENT-IND=LINE-ADJUSTMENT-IND.

STEP 5: Medicaid and S-CHIP Encounter: Paid Claims

Of the claims that meet the criteria from STEP 4, further restrict them by the following criteria:

1. TYPE-OF-CLAIM = ("3" or "C")

STEP 6: Capitation payment financial transactions:

Define the FTX universe for the FTX0002, FTX0003, and FTX0005 tables respectively by keeping active records that satisfy the following criteria:

1. Reporting Period from the filename = DQ report month

2. No Duplicates: Duplicates are dropped at the table level, if the following four data elements are the same: ICN-ORIG, ICN-ADJ, PAYMENT-DATE or PAYMENT-OR-RECOUPMENT-DATE, and ADJUSTMENT-IND.

STEP 7: Medicaid & S-CHIP Capitation Payment

Of the financial transactions that meet the criteria from STEP 6, further restrict them by the following criteria:

1. PAYEE-ID-TYPE = ("02" or "05" or "06")

For those in FTX0005 only:

1. OFFSET-TRANS-TYPE = "1" or "2"

STEP 8: Define Plan_Id

Define Plan_Id as a unique list of: MANAGED-CARE-PLAN-ID from the EL file that meet the constraints in STEP 2, STATE-PLAN-ID-NUM from the MCR file that meet the constraints in STEP 3, PLAN-ID-NUMBER from the claims files that meet the constraints in STEP 5, and PAYEE-ID from records that meet constraints in STEP 7. Also, define a blank Plan_Id for missing.

STEP 9: Define Plan_Type_El

In cases where Plan_Id can be linked to a MANAGED-CARE-PLAN-ID in MANAGED-CARE-PARTICIPATION-ELG00014, and there is only one plan type for that plan, define Plan_Type_El as MANAGED-CARE-PLAN-TYPE. If there are multiple plan types for the Plan_Id, then set Plan_Type_El to the most frequently used plan type, or the lowest plan type if there is a tie. (If there are multiple plan types, also set MultiplePlanTypes_EL = 1.) In all other cases, Plan_Type_El = missing.

STEP 10: Define Plan_Type_Mc and Linked

In cases where Plan_Id can be linked to a STATE-PLAN-ID-NUM in MANAGED-CARE-MAIN-MCR00002, set In_MCR_File = "Yes". If there is only one plan type for that plan, define Plan_Type_Mc as MANAGED-CARE-PLAN-TYPE . If there are multiple plan types for the Plan_Id, then set Plan_Type_Mc to the most frequently used plan type, or the lowest plan type if there is a tie. (If there are multiple plan types, also set MultiplePlanTypes_Mc = 1.) In all other cases, Plan_Type_Mc = missing and In_MCR_File = "No".

STEP 11: Count Enrollment

For each Plan_Id, define Enrollment as the count of unique MSIS-IDENTIFICATION-NUM that satisfy the constraints in STEP 2a

STEP 12: Capitation Records

For each record that meets the criteria from STEP 7, further restrict them by the following criteria:

1. ADJUSTMENT_IND = 0

2a. PAYMENT_OR_RECOUPMENT_AMOUNT (FTX00002 and FTX00005) > 0

OR

2b. PAYMENT_AMOUNT (FTX00003) > 0

STEP 13: Set Capitation Type

Using the records in STEP 12:

1a. Set Capitation_Type = “Medicaid and S-CHIP” if at least one record with MBESCBES_FORM_GROUP = "1" OR "2" AND at least one record with MBESCBES_FORM_GROUP = "3"

1b. Set Capitation_Type = “Medicaid” if at least one record with MBESCBES_FORM_GROUP = "1" OR "2" AND no records with MBESCBES_FORM_GROUP = "3"

1c. Set Capitation_Type = "S-CHIP" if no records with MBESCBES_FORM_GROUP = "1" OR "2" AND at least one record with MBESCBES_FORM_GROUP = "3"

STEP 14: Count Capitation_Hmo_Hio_Pace

Define Capitation_Hmo_Hio_Pace as the count of unique FTX00002 records from STEP 12 that also satisfy the following criteria:

1. PAYEE-MCR-PLAN-TYPE = (“01” or “04” or “17”)

STEP 15: Count Capitation_Php

Define Capitation_Php as the count of unique FTX00002 records from STEP 12 that also satisfy the following criteria:

1. PAYEE-MCR-PLAN-TYPE = (“05” or “06”or “07”or “08”or “09” or “10” or “11”or “12” or “13”or “14” or “15”or “16” or “18”or “19”)

STEP 16: Count Capitation_Pccm

Define Capitation_Pccm as the count of unique FTX00002 records from STEP 12 that also satisfy the following criteria:

1. PAYEE-MCR-PLAN-TYPE = (“02" or "03")

STEP 17: Count Capitation_Phi

Define Capitation_Phi as the count of unique FTX00003 and FTX00005 records from STEP 12 that also satisfy the following criteria:

1. For FTX00005 records only, OFFSET-TRANS-TYPE = "2"

STEP 18: Count Capitation_Other

Define Capitation_Other as the count of unique FTX00002 and FTX00005 records from STEP 12 that also satisfy the following criteria:

1. PAYEE-MCR-PLAN-TYPE is not equal to (“01”,“02”,“03”,“04”, “05”,“06”,“07”,“08”,“09”,“10”,“11”,“12”,“13”,“14”,“15”,“16”, “17”,“18”,“19”)

2. For FTX00005 records only, OFFSET-TRANS-TYPE = "1"

STEP 19: Count Capitation_Total

Define Capitation_Total as the sum of Capitation_Hmo_Hio_Pace, Capitation_Php, Capitation_Pccm, Capitation_Phi, and Capitation_Other

STEP 20: Encounter Claims

Select encounter claims in the IP, LT, OT, and RX files by the following criteria:

1. PLAN-ID-NUMBER = Plan_Id

2. TYPE-OF-CLAIM = (“3” or “C”)

3. ADJUSTMENT-IND = “0”

STEP 21: Set Encounter Type

Using the records in STEP 20:

1a. Set Encounter_Type = “Medicaid and S-CHIP” if at least one record with TYPE-OF-CLAIM = “3” AND at least one record with TYPE-OF-CLAIM = “C”

1b. Set Encounter_Type = “Medicaid” if at least one record with TYPE-OF-CLAIM = “3” AND no records with TYPE-OF-CLAIM = “C”

1c. Set Encounter_Type = "S-CHIP" if no records with TYPE-OF-CLAIM = “3” AND at least one record with TYPE-OF-CLAIM = “C”

STEP 22: Count Encounters_Ip

Define Encounters_Ip as the count of unique IP header records from STEP 20

STEP 23: Count Encounters_Lt

Define Encounters_Lt as the count of unique LT header records from STEP 20

STEP 24: Count Encounters_Ot

Define Encounters_Ot as the count of unique OT line records from STEP 20

STEP 25: Count Encounters_Rx

Define Encounters_Rx as the count of unique RX header records from STEP 20

STEP 26: Count Encounters_Total

Define Encounters_Total as the sum of Encounters_Ip, Encounters_Lt, Encounters_Ot, and Encounters_Rx

STEP 27: Count Ratios

SET Capitation_Ratio = Capitation_Total / Enrollment

SET Encounters_Ip_Ratio = Encounters_Ip / Enrollment

SET Encounters_Lt_Ratio = Encounters_Lt / Enrollment

SET Encounters_Ot_Ratio = Encounters_Ot / Enrollment

SET Encounters_Rx_Ratio = Encounters_Rx / Enrollment

STEP 28: Repeat for each Plan_Id

REPEAT STEPS 9-27 for each Plan_Id identified in STEP 8

Published Date	Data Guide Version	DQM	Action	Field	Before	After
10/07/2025	4.0.19	EL-8-002-2	UPDATE	Specification	STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Managed care enrollment on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 1, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 3: Managed care plans on the last day of DQ report monthDefine the managed care plan population from segment MANAGED-CARE-MAIN-MCR00002 by keeping active records that satisfy the following criteria:1. MANAGED-CARE-MAIN-REC-EFF-DATE <= last day of the reporting month2. MANAGED-CARE-MAIN-REC-END-DATE >= last day of the reporting month OR missingSTEP 4: Active non-duplicate claims records during DQ report monthDefine the claims universe for IP, LT, and RX at the header level and for OT at the line level by importing headers (and lines for OT) 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, and ADJUDICATION-DATE and ADJUSTMENT-IND=LINE-ADJUSTMENT-IND.STEP 5: Medicaid and S-CHIP Encounter: Paid ClaimsOf the claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-CLAIM = ("3" or "C")STEP 6: Capitation payment financial transactions:Define the FTX universe for the FTX0002, FTX0003, and FTX0005 tables respectively by keeping active records that satisfy the following criteria:1. Reporting Period from the filename = DQ report month2. No Duplicates: Duplicates are dropped at the table level, if the following four data elements are the same: ICN-ORIG, ICN-ADJ, PAYMENT-DATE or PAYMENT-OR-RECOUPMENT-DATE, and ADJUSTMENT-IND.STEP 7: Medicaid & S-CHIP Capitation PaymentOf the financial transactions that meet the criteria from STEP 6, further restrict them by the following criteria:1. PAYEE-ID-TYPE = "02"For those in FTX0005 only:1. OFFSET-TRANS-TYPE = "1" or "2"STEP 8: Define Plan_IdDefine Plan_Id as a unique list of: MANAGED-CARE-PLAN-ID from the EL file that meet the constraints in STEP 2, STATE-PLAN-ID-NUM from the MCR file that meet the constraints in STEP 3, PLAN-ID-NUMBER from the claims files that meet the constraints in STEP 5, and PAYEE-ID from records that meet constraints in STEP 7. Also, define a blank Plan_Id for missing.STEP 9: Define Plan_Type_ElIn cases where Plan_Id can be linked to a MANAGED-CARE-PLAN-ID in MANAGED-CARE-PARTICIPATION-ELG00014, and there is only one plan type for that plan, define Plan_Type_El as MANAGED-CARE-PLAN-TYPE. If there are multiple plan types for the Plan_Id, then set Plan_Type_El to the most frequently used plan type, or the lowest plan type if there is a tie. (If there are multiple plan types, also set MultiplePlanTypes_EL = 1.) In all other cases, Plan_Type_El = missing.STEP 10: Define Plan_Type_Mc and LinkedIn cases where Plan_Id can be linked to a STATE-PLAN-ID-NUM in MANAGED-CARE-MAIN-MCR00002, set In_MCR_File = "Yes". If there is only one plan type for that plan, define Plan_Type_Mc as MANAGED-CARE-PLAN-TYPE . If there are multiple plan types for the Plan_Id, then set Plan_Type_Mc to the most frequently used plan type, or the lowest plan type if there is a tie. (If there are multiple plan types, also set MultiplePlanTypes_Mc = 1.) In all other cases, Plan_Type_Mc = missing and In_MCR_File = "No". STEP 11: Count EnrollmentFor each Plan_Id, define Enrollment as the count of unique MSIS-IDENTIFICATION-NUM that satisfy the constraints in STEP 2aSTEP 12: Capitation RecordsFor each record that meets the criteria from STEP 7, further restrict them by the following criteria:1. ADJUSTMENT_IND = 02a. PAYMENT_OR_RECOUPMENT_AMOUNT (FTX00002 and FTX00005) > 0OR2b. PAYMENT_AMOUNT (FTX00003) > 0STEP 13: Set Capitation TypeUsing the records in STEP 12:1a. Set Capitation_Type = “Medicaid and S-CHIP” if at least one record with MBESCBES_FORM_GROUP = "1" OR "2" AND at least one record with MBESCBES_FORM_GROUP = "3" 1b. Set Capitation_Type = “Medicaid” if at least one record with MBESCBES_FORM_GROUP = "1" OR "2" AND no records with MBESCBES_FORM_GROUP = "3"1c. Set Capitation_Type = "S-CHIP" if no records with MBESCBES_FORM_GROUP = "1" OR "2" AND at least one record with MBESCBES_FORM_GROUP = "3" STEP 14: Count Capitation_Hmo_Hio_PaceDefine Capitation_Hmo_Hio_Pace as the count of unique FTX00002 records from STEP 12 that also satisfy the following criteria:1. PAYEE-MCR-PLAN-TYPE = (“01” or “04” or “17”)STEP 15: Count Capitation_PhpDefine Capitation_Php as the count of unique FTX00002 records from STEP 12 that also satisfy the following criteria:1. PAYEE-MCR-PLAN-TYPE = (“05” or “06”or “07”or “08”or “09” or “10” or “11”or “12” or “13”or “14” or “15”or “16” or “18”or “19”)STEP 16: Count Capitation_PccmDefine Capitation_Pccm as the count of unique FTX00002 records from STEP 12 that also satisfy the following criteria:1. PAYEE-MCR-PLAN-TYPE = (“02" or "03")STEP 17: Count Capitation_PhiDefine Capitation_Phi as the count of unique FTX00003 and FTX00005 records from STEP 12 that also satisfy the following criteria:1. For FTX00005 records only, OFFSET-TRANS-TYPE = "2"STEP 18: Count Capitation_OtherDefine Capitation_Other as the count of unique FTX00002 and FTX00005 records from STEP 12 that also satisfy the following criteria:1. PAYEE-MCR-PLAN-TYPE is not equal to (“01”,“02”,“03”,“04”, “05”,“06”,“07”,“08”,“09”,“10”,“11”,“12”,“13”,“14”,“15”,“16”, “17”,“18”,“19”) 2. For FTX00005 records only, OFFSET-TRANS-TYPE = "1"STEP 19: Count Capitation_TotalDefine Capitation_Total as the sum of Capitation_Hmo_Hio_Pace, Capitation_Php, Capitation_Pccm, Capitation_Phi, and Capitation_OtherSTEP 20: Encounter ClaimsSelect encounter claims in the IP, LT, OT, and RX files by the following criteria:1. PLAN-ID-NUMBER = Plan_Id2. TYPE-OF-CLAIM = (“3” or “C”)3. ADJUSTMENT-IND = “0”STEP 21: Set Encounter TypeUsing the records in STEP 20:1a. Set Encounter_Type = “Medicaid and S-CHIP” if at least one record with TYPE-OF-CLAIM = “3” AND at least one record with TYPE-OF-CLAIM = “C” 1b. Set Encounter_Type = “Medicaid” if at least one record with TYPE-OF-CLAIM = “3” AND no records with TYPE-OF-CLAIM = “C” 1c. Set Encounter_Type = "S-CHIP" if no records with TYPE-OF-CLAIM = “3” AND at least one record with TYPE-OF-CLAIM = “C”STEP 22: Count Encounters_IpDefine Encounters_Ip as the count of unique IP header records from STEP 20STEP 23: Count Encounters_LtDefine Encounters_Lt as the count of unique LT header records from STEP 20STEP 24: Count Encounters_OtDefine Encounters_Ot as the count of unique OT line records from STEP 20STEP 25: Count Encounters_RxDefine Encounters_Rx as the count of unique RX header records from STEP 20STEP 26: Count Encounters_TotalDefine Encounters_Total as the sum of Encounters_Ip, Encounters_Lt, Encounters_Ot, and Encounters_RxSTEP 27: Count RatiosSET Capitation_Ratio = Capitation_Total / EnrollmentSET Encounters_Ip_Ratio = Encounters_Ip / EnrollmentSET Encounters_Lt_Ratio = Encounters_Lt / EnrollmentSET Encounters_Ot_Ratio = Encounters_Ot / EnrollmentSET Encounters_Rx_Ratio = Encounters_Rx / EnrollmentSTEP 28: Repeat for each Plan_IdREPEAT STEPS 9-27 for each Plan_Id identified in STEP 8	STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Managed care enrollment on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 1, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 3: Managed care plans on the last day of DQ report monthDefine the managed care plan population from segment MANAGED-CARE-MAIN-MCR00002 by keeping active records that satisfy the following criteria:1. MANAGED-CARE-MAIN-REC-EFF-DATE <= last day of the reporting month2. MANAGED-CARE-MAIN-REC-END-DATE >= last day of the reporting month OR missingSTEP 4: Active non-duplicate claims records during DQ report monthDefine the claims universe for IP, LT, and RX at the header level and for OT at the line level by importing headers (and lines for OT) 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, and ADJUDICATION-DATE and ADJUSTMENT-IND=LINE-ADJUSTMENT-IND.STEP 5: Medicaid and S-CHIP Encounter: Paid ClaimsOf the claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-CLAIM = ("3" or "C")STEP 6: Capitation payment financial transactions:Define the FTX universe for the FTX0002, FTX0003, and FTX0005 tables respectively by keeping active records that satisfy the following criteria:1. Reporting Period from the filename = DQ report month2. No Duplicates: Duplicates are dropped at the table level, if the following four data elements are the same: ICN-ORIG, ICN-ADJ, PAYMENT-DATE or PAYMENT-OR-RECOUPMENT-DATE, and ADJUSTMENT-IND.STEP 7: Medicaid & S-CHIP Capitation PaymentOf the financial transactions that meet the criteria from STEP 6, further restrict them by the following criteria:1. PAYEE-ID-TYPE = ("02" or "05" or "06")For those in FTX0005 only:1. OFFSET-TRANS-TYPE = "1" or "2"STEP 8: Define Plan_IdDefine Plan_Id as a unique list of: MANAGED-CARE-PLAN-ID from the EL file that meet the constraints in STEP 2, STATE-PLAN-ID-NUM from the MCR file that meet the constraints in STEP 3, PLAN-ID-NUMBER from the claims files that meet the constraints in STEP 5, and PAYEE-ID from records that meet constraints in STEP 7. Also, define a blank Plan_Id for missing.STEP 9: Define Plan_Type_ElIn cases where Plan_Id can be linked to a MANAGED-CARE-PLAN-ID in MANAGED-CARE-PARTICIPATION-ELG00014, and there is only one plan type for that plan, define Plan_Type_El as MANAGED-CARE-PLAN-TYPE. If there are multiple plan types for the Plan_Id, then set Plan_Type_El to the most frequently used plan type, or the lowest plan type if there is a tie. (If there are multiple plan types, also set MultiplePlanTypes_EL = 1.) In all other cases, Plan_Type_El = missing.STEP 10: Define Plan_Type_Mc and LinkedIn cases where Plan_Id can be linked to a STATE-PLAN-ID-NUM in MANAGED-CARE-MAIN-MCR00002, set In_MCR_File = "Yes". If there is only one plan type for that plan, define Plan_Type_Mc as MANAGED-CARE-PLAN-TYPE . If there are multiple plan types for the Plan_Id, then set Plan_Type_Mc to the most frequently used plan type, or the lowest plan type if there is a tie. (If there are multiple plan types, also set MultiplePlanTypes_Mc = 1.) In all other cases, Plan_Type_Mc = missing and In_MCR_File = "No". STEP 11: Count EnrollmentFor each Plan_Id, define Enrollment as the count of unique MSIS-IDENTIFICATION-NUM that satisfy the constraints in STEP 2aSTEP 12: Capitation RecordsFor each record that meets the criteria from STEP 7, further restrict them by the following criteria:1. ADJUSTMENT_IND = 02a. PAYMENT_OR_RECOUPMENT_AMOUNT (FTX00002 and FTX00005) > 0OR2b. PAYMENT_AMOUNT (FTX00003) > 0STEP 13: Set Capitation TypeUsing the records in STEP 12:1a. Set Capitation_Type = “Medicaid and S-CHIP” if at least one record with MBESCBES_FORM_GROUP = "1" OR "2" AND at least one record with MBESCBES_FORM_GROUP = "3" 1b. Set Capitation_Type = “Medicaid” if at least one record with MBESCBES_FORM_GROUP = "1" OR "2" AND no records with MBESCBES_FORM_GROUP = "3"1c. Set Capitation_Type = "S-CHIP" if no records with MBESCBES_FORM_GROUP = "1" OR "2" AND at least one record with MBESCBES_FORM_GROUP = "3" STEP 14: Count Capitation_Hmo_Hio_PaceDefine Capitation_Hmo_Hio_Pace as the count of unique FTX00002 records from STEP 12 that also satisfy the following criteria:1. PAYEE-MCR-PLAN-TYPE = (“01” or “04” or “17”)STEP 15: Count Capitation_PhpDefine Capitation_Php as the count of unique FTX00002 records from STEP 12 that also satisfy the following criteria:1. PAYEE-MCR-PLAN-TYPE = (“05” or “06”or “07”or “08”or “09” or “10” or “11”or “12” or “13”or “14” or “15”or “16” or “18”or “19”)STEP 16: Count Capitation_PccmDefine Capitation_Pccm as the count of unique FTX00002 records from STEP 12 that also satisfy the following criteria:1. PAYEE-MCR-PLAN-TYPE = (“02" or "03")STEP 17: Count Capitation_PhiDefine Capitation_Phi as the count of unique FTX00003 and FTX00005 records from STEP 12 that also satisfy the following criteria:1. For FTX00005 records only, OFFSET-TRANS-TYPE = "2"STEP 18: Count Capitation_OtherDefine Capitation_Other as the count of unique FTX00002 and FTX00005 records from STEP 12 that also satisfy the following criteria:1. PAYEE-MCR-PLAN-TYPE is not equal to (“01”,“02”,“03”,“04”, “05”,“06”,“07”,“08”,“09”,“10”,“11”,“12”,“13”,“14”,“15”,“16”, “17”,“18”,“19”) 2. For FTX00005 records only, OFFSET-TRANS-TYPE = "1"STEP 19: Count Capitation_TotalDefine Capitation_Total as the sum of Capitation_Hmo_Hio_Pace, Capitation_Php, Capitation_Pccm, Capitation_Phi, and Capitation_OtherSTEP 20: Encounter ClaimsSelect encounter claims in the IP, LT, OT, and RX files by the following criteria:1. PLAN-ID-NUMBER = Plan_Id2. TYPE-OF-CLAIM = (“3” or “C”)3. ADJUSTMENT-IND = “0”STEP 21: Set Encounter TypeUsing the records in STEP 20:1a. Set Encounter_Type = “Medicaid and S-CHIP” if at least one record with TYPE-OF-CLAIM = “3” AND at least one record with TYPE-OF-CLAIM = “C” 1b. Set Encounter_Type = “Medicaid” if at least one record with TYPE-OF-CLAIM = “3” AND no records with TYPE-OF-CLAIM = “C” 1c. Set Encounter_Type = "S-CHIP" if no records with TYPE-OF-CLAIM = “3” AND at least one record with TYPE-OF-CLAIM = “C”STEP 22: Count Encounters_IpDefine Encounters_Ip as the count of unique IP header records from STEP 20STEP 23: Count Encounters_LtDefine Encounters_Lt as the count of unique LT header records from STEP 20STEP 24: Count Encounters_OtDefine Encounters_Ot as the count of unique OT line records from STEP 20STEP 25: Count Encounters_RxDefine Encounters_Rx as the count of unique RX header records from STEP 20STEP 26: Count Encounters_TotalDefine Encounters_Total as the sum of Encounters_Ip, Encounters_Lt, Encounters_Ot, and Encounters_RxSTEP 27: Count RatiosSET Capitation_Ratio = Capitation_Total / EnrollmentSET Encounters_Ip_Ratio = Encounters_Ip / EnrollmentSET Encounters_Lt_Ratio = Encounters_Lt / EnrollmentSET Encounters_Ot_Ratio = Encounters_Ot / EnrollmentSET Encounters_Rx_Ratio = Encounters_Rx / EnrollmentSTEP 28: Repeat for each Plan_IdREPEAT STEPS 9-27 for each Plan_Id identified in STEP 8
08/13/2025	4.0.16	EL-8-002-2	UPDATE	Specification	STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Managed care enrollment on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 1, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 3: Managed care plans on the last day of DQ report monthDefine the managed care plan population from segment MANAGED-CARE-MAIN-MCR00002 by keeping active records that satisfy the following criteria:1. MANAGED-CARE-MAIN-REC-EFF-DATE <= last day of the reporting month2. MANAGED-CARE-MAIN-REC-END-DATE >= last day of the reporting month OR missingSTEP 4: Active non-duplicate claims records during DQ report monthDefine the claims universe for IP, LT, and RX at the header level and for OT at the line level by importing headers (and lines for OT) 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, and ADJUDICATION-DATE and ADJUSTMENT-IND=LINE-ADJSTMT-IND.STEP 5: Medicaid and S-CHIP Capitation Payment and Encounter: Paid ClaimsOf the claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-CLAIM = (“2” or "3" or “B” or "C")STEP 6: Capitation payment financial transactions:Define the FTX universe for the FTX0002, FTX0003, and FTX0005 tables respectively by keeping active records that satisfy the following criteria:1. Reporting Period from the filename = DQ report month2. No Duplicates: Duplicates are dropped at the table level, if the following four data elements are the same: ICN-ORIG, ICN-ADJ, PAYMENT-DATE or PAYMENT-OR-RECOUPMENT-DATE, and ADJUSTMENT-IND.STEP 7: Medicaid & S-CHIP Capitation PaymentOf the financial transactions that meet the criteria from STEP 6, further restrict them by the following criteria:1. PAYEE-ID-TYPE = "02"For those in FTX0005 only:1. OFFSET-TRANS-TYPE = "1" or "2"STEP 8: Define Plan_IdDefine Plan_Id as a unique list of: MANAGED-CARE-PLAN-ID from the EL file that meet the constraints in STEP 2, STATE-PLAN-ID-NUM from the MCR file that meet the constraints in STEP 3, PLAN-ID-NUMBER from the claims files that meet the constraints in STEP 5, and PAYEE-ID from records that meet constraints in STEP 7. Also, define a blank Plan_Id for missing.STEP 9: Define Plan_Type_ElIn cases where Plan_Id can be linked to a MANAGED-CARE-PLAN-ID in MANAGED-CARE-PARTICIPATION-ELG00014, and there is only one plan type for that plan, define Plan_Type_El as MANAGED-CARE-PLAN-TYPE. If there are multiple plan types for the Plan_Id, then set Plan_Type_El to the most frequently used plan type, or the lowest plan type if there is a tie. (If there are multiple plan types, also set MultiplePlanTypes_EL = 1.) In all other cases, Plan_Type_El = missing.STEP 10: Define Plan_Type_Mc and LinkedIn cases where Plan_Id can be linked to a STATE-PLAN-ID-NUM in MANAGED-CARE-MAIN-MCR00002, set In_MCR_File = "Yes". If there is only one plan type for that plan, define Plan_Type_Mc as MANAGED-CARE-PLAN-TYPE . If there are multiple plan types for the Plan_Id, then set Plan_Type_Mc to the most frequently used plan type, or the lowest plan type if there is a tie. (If there are multiple plan types, also set MultiplePlanTypes_Mc = 1.) In all other cases, Plan_Type_Mc = missing and In_MCR_File = "No". STEP 11: Count EnrollmentFor each Plan_Id, define Enrollment as the count of unique MSIS-IDENTIFICATION-NUM that satisfy the constraints in STEP 2aSTEP 12: Capitation RecordsFor each record that meets the criteria from STEP 7, further restrict them by the following criteria:1. ADJUSTMENT_IND = 02a. PAYMENT_OR_RECOUPMENT_AMOUNT (FTX00002 and FTX00005) > 0OR2b. PAYMENT_AMOUNT (FTX00003) > 0STEP 13: Set Capitation TypeUsing the records in STEP 12:1a. Set Capitation_Type = “Medicaid and S-CHIP” if at least one record with MBESCBES_FORM_GROUP = "1" OR "2" AND at least one record with MBESCBES_FORM_GROUP = "3" 1b. Set Capitation_Type = “Medicaid” if at least one record with MBESCBES_FORM_GROUP = "1" OR "2" AND no records with MBESCBES_FORM_GROUP = "3"1c. Set Capitation_Type = "S-CHIP" if no records with MBESCBES_FORM_GROUP = "1" OR "2" AND at least one record with MBESCBES_FORM_GROUP = "3" STEP 14: Count Capitation_Hmo_Hio_PaceDefine Capitation_Hmo_Hio_Pace as the count of unique FTX00002 records from STEP 12 that also satisfy the following criteria:1. PAYEE_MCR_PLAN_TYPE = (“01” or “04” or “17”)STEP 15: Count Capitation_PhpDefine Capitation_Php as the count of unique FTX00002 records from STEP 12 that also satisfy the following criteria:1. PAYEE_MCR_PLAN_TYPE = (“05” or “06”or “07”or “08”or “09” or “10” or “11”or “12” or “13”or “14” or “15”or “16” or “18”or “19”)STEP 16: Count Capitation_PccmDefine Capitation_Pccm as the count of unique FTX00002 records from STEP 12 that also satisfy the following criteria:1. PAYEE_MCR_PLAN_TYPE = (“02" or "03")STEP 17: Count Capitation_PhiDefine Capitation_Phi as the count of unique FTX00003 and FTX00005 records from STEP 12 that also satisfy the following criteria:1. For FTX00005 records only, OFFSET_TRANS_TYPE = "2"STEP 18: Count Capitation_OtherDefine Capitation_Other as the count of unique FTX00002 and FTX00005 records from STEP 12 that also satisfy the following criteria:1. PAYEE_MCR_PLAN_TYPE is not equal to (“01”,“02”,“03”,“04”, “05”,“06”,“07”,“08”,“09”,“10”,“11”,“12”,“13”,“14”,“15”,“16”, “17”,“18”,“19”) 2. For FTX00005 records only, OFFSET_TRANS_TYPE = "1"STEP 19: Count Capitation_TotalDefine Capitation_Total as the sum of Capitation_Hmo_Hio_Pace, Capitation_Php, Capitation_Pccm, Capitation_Phi, and Capitation_OtherSTEP 20: Encounter ClaimsSelect encounter claims in the IP, LT, OT, and RX files by the following criteria:1. PLAN-ID-NUMBER = Plan_Id2. TYPE-OF-CLAIM = (“3” or “C”)3. ADJUSTMENT-IND = “0”STEP 21: Set Encounter TypeUsing the records in STEP 20:1a. Set Encounter_Type = “Medicaid and S-CHIP” if at least one record with TYPE-OF-CLAIM = “3” AND at least one record with TYPE-OF-CLAIM = “C” 1b. Set Encounter_Type = “Medicaid” if at least one record with TYPE-OF-CLAIM = “3” AND no records with TYPE-OF-CLAIM = “C” 1c. Set Encounter_Type = "S-CHIP" if no records with TYPE-OF-CLAIM = “3” AND at least one record with TYPE-OF-CLAIM = “C”STEP 22: Count Encounters_IpDefine Encounters_Ip as the count of unique IP header records from STEP 20STEP 23: Count Encounters_LtDefine Encounters_Lt as the count of unique LT header records from STEP 20STEP 24: Count Encounters_OtDefine Encounters_Ot as the count of unique OT line records from STEP 20STEP 25: Count Encounters_RxDefine Encounters_Rx as the count of unique RX header records from STEP 20STEP 26: Count Encounters_TotalDefine Encounters_Total as the sum of Encounters_Ip, Encounters_Lt, Encounters_Ot, and Encounters_RxSTEP 27: Count RatiosSET Capitation_Ratio = Capitation_Total / EnrollmentSET Encounters_Ip_Ratio = Encounters_Ip / EnrollmentSET Encounters_Lt_Ratio = Encounters_Lt / EnrollmentSET Encounters_Ot_Ratio = Encounters_Ot / EnrollmentSET Encounters_Rx_Ratio = Encounters_Rx / EnrollmentSTEP 28: Repeat for each Plan_IdREPEAT STEPS 9-27 for each Plan_Id identified in STEP 8	STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Managed care enrollment on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 1, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 3: Managed care plans on the last day of DQ report monthDefine the managed care plan population from segment MANAGED-CARE-MAIN-MCR00002 by keeping active records that satisfy the following criteria:1. MANAGED-CARE-MAIN-REC-EFF-DATE <= last day of the reporting month2. MANAGED-CARE-MAIN-REC-END-DATE >= last day of the reporting month OR missingSTEP 4: Active non-duplicate claims records during DQ report monthDefine the claims universe for IP, LT, and RX at the header level and for OT at the line level by importing headers (and lines for OT) 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, and ADJUDICATION-DATE and ADJUSTMENT-IND=LINE-ADJUSTMENT-IND.STEP 5: Medicaid and S-CHIP Encounter: Paid ClaimsOf the claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-CLAIM = ("3" or "C")STEP 6: Capitation payment financial transactions:Define the FTX universe for the FTX0002, FTX0003, and FTX0005 tables respectively by keeping active records that satisfy the following criteria:1. Reporting Period from the filename = DQ report month2. No Duplicates: Duplicates are dropped at the table level, if the following four data elements are the same: ICN-ORIG, ICN-ADJ, PAYMENT-DATE or PAYMENT-OR-RECOUPMENT-DATE, and ADJUSTMENT-IND.STEP 7: Medicaid & S-CHIP Capitation PaymentOf the financial transactions that meet the criteria from STEP 6, further restrict them by the following criteria:1. PAYEE-ID-TYPE = "02"For those in FTX0005 only:1. OFFSET-TRANS-TYPE = "1" or "2"STEP 8: Define Plan_IdDefine Plan_Id as a unique list of: MANAGED-CARE-PLAN-ID from the EL file that meet the constraints in STEP 2, STATE-PLAN-ID-NUM from the MCR file that meet the constraints in STEP 3, PLAN-ID-NUMBER from the claims files that meet the constraints in STEP 5, and PAYEE-ID from records that meet constraints in STEP 7. Also, define a blank Plan_Id for missing.STEP 9: Define Plan_Type_ElIn cases where Plan_Id can be linked to a MANAGED-CARE-PLAN-ID in MANAGED-CARE-PARTICIPATION-ELG00014, and there is only one plan type for that plan, define Plan_Type_El as MANAGED-CARE-PLAN-TYPE. If there are multiple plan types for the Plan_Id, then set Plan_Type_El to the most frequently used plan type, or the lowest plan type if there is a tie. (If there are multiple plan types, also set MultiplePlanTypes_EL = 1.) In all other cases, Plan_Type_El = missing.STEP 10: Define Plan_Type_Mc and LinkedIn cases where Plan_Id can be linked to a STATE-PLAN-ID-NUM in MANAGED-CARE-MAIN-MCR00002, set In_MCR_File = "Yes". If there is only one plan type for that plan, define Plan_Type_Mc as MANAGED-CARE-PLAN-TYPE . If there are multiple plan types for the Plan_Id, then set Plan_Type_Mc to the most frequently used plan type, or the lowest plan type if there is a tie. (If there are multiple plan types, also set MultiplePlanTypes_Mc = 1.) In all other cases, Plan_Type_Mc = missing and In_MCR_File = "No". STEP 11: Count EnrollmentFor each Plan_Id, define Enrollment as the count of unique MSIS-IDENTIFICATION-NUM that satisfy the constraints in STEP 2aSTEP 12: Capitation RecordsFor each record that meets the criteria from STEP 7, further restrict them by the following criteria:1. ADJUSTMENT_IND = 02a. PAYMENT_OR_RECOUPMENT_AMOUNT (FTX00002 and FTX00005) > 0OR2b. PAYMENT_AMOUNT (FTX00003) > 0STEP 13: Set Capitation TypeUsing the records in STEP 12:1a. Set Capitation_Type = “Medicaid and S-CHIP” if at least one record with MBESCBES_FORM_GROUP = "1" OR "2" AND at least one record with MBESCBES_FORM_GROUP = "3" 1b. Set Capitation_Type = “Medicaid” if at least one record with MBESCBES_FORM_GROUP = "1" OR "2" AND no records with MBESCBES_FORM_GROUP = "3"1c. Set Capitation_Type = "S-CHIP" if no records with MBESCBES_FORM_GROUP = "1" OR "2" AND at least one record with MBESCBES_FORM_GROUP = "3" STEP 14: Count Capitation_Hmo_Hio_PaceDefine Capitation_Hmo_Hio_Pace as the count of unique FTX00002 records from STEP 12 that also satisfy the following criteria:1. PAYEE-MCR-PLAN-TYPE = (“01” or “04” or “17”)STEP 15: Count Capitation_PhpDefine Capitation_Php as the count of unique FTX00002 records from STEP 12 that also satisfy the following criteria:1. PAYEE-MCR-PLAN-TYPE = (“05” or “06”or “07”or “08”or “09” or “10” or “11”or “12” or “13”or “14” or “15”or “16” or “18”or “19”)STEP 16: Count Capitation_PccmDefine Capitation_Pccm as the count of unique FTX00002 records from STEP 12 that also satisfy the following criteria:1. PAYEE-MCR-PLAN-TYPE = (“02" or "03")STEP 17: Count Capitation_PhiDefine Capitation_Phi as the count of unique FTX00003 and FTX00005 records from STEP 12 that also satisfy the following criteria:1. For FTX00005 records only, OFFSET-TRANS-TYPE = "2"STEP 18: Count Capitation_OtherDefine Capitation_Other as the count of unique FTX00002 and FTX00005 records from STEP 12 that also satisfy the following criteria:1. PAYEE-MCR-PLAN-TYPE is not equal to (“01”,“02”,“03”,“04”, “05”,“06”,“07”,“08”,“09”,“10”,“11”,“12”,“13”,“14”,“15”,“16”, “17”,“18”,“19”) 2. For FTX00005 records only, OFFSET-TRANS-TYPE = "1"STEP 19: Count Capitation_TotalDefine Capitation_Total as the sum of Capitation_Hmo_Hio_Pace, Capitation_Php, Capitation_Pccm, Capitation_Phi, and Capitation_OtherSTEP 20: Encounter ClaimsSelect encounter claims in the IP, LT, OT, and RX files by the following criteria:1. PLAN-ID-NUMBER = Plan_Id2. TYPE-OF-CLAIM = (“3” or “C”)3. ADJUSTMENT-IND = “0”STEP 21: Set Encounter TypeUsing the records in STEP 20:1a. Set Encounter_Type = “Medicaid and S-CHIP” if at least one record with TYPE-OF-CLAIM = “3” AND at least one record with TYPE-OF-CLAIM = “C” 1b. Set Encounter_Type = “Medicaid” if at least one record with TYPE-OF-CLAIM = “3” AND no records with TYPE-OF-CLAIM = “C” 1c. Set Encounter_Type = "S-CHIP" if no records with TYPE-OF-CLAIM = “3” AND at least one record with TYPE-OF-CLAIM = “C”STEP 22: Count Encounters_IpDefine Encounters_Ip as the count of unique IP header records from STEP 20STEP 23: Count Encounters_LtDefine Encounters_Lt as the count of unique LT header records from STEP 20STEP 24: Count Encounters_OtDefine Encounters_Ot as the count of unique OT line records from STEP 20STEP 25: Count Encounters_RxDefine Encounters_Rx as the count of unique RX header records from STEP 20STEP 26: Count Encounters_TotalDefine Encounters_Total as the sum of Encounters_Ip, Encounters_Lt, Encounters_Ot, and Encounters_RxSTEP 27: Count RatiosSET Capitation_Ratio = Capitation_Total / EnrollmentSET Encounters_Ip_Ratio = Encounters_Ip / EnrollmentSET Encounters_Lt_Ratio = Encounters_Lt / EnrollmentSET Encounters_Ot_Ratio = Encounters_Ot / EnrollmentSET Encounters_Rx_Ratio = Encounters_Rx / EnrollmentSTEP 28: Repeat for each Plan_IdREPEAT STEPS 9-27 for each Plan_Id identified in STEP 8
04/24/2025	4.0.7	EL-8-002-2	ADD	N/A		Created