| 11/20/2025 |
4.0.22 |
EL-8-002-2 |
UPDATE |
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. |
N/A |
| 11/20/2025 |
4.0.22 |
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" 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 |
N/A |
| 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 |
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