EXP-1-013-4

Data Quality Measure

Last updated

Key Information

Measure Name	Average Total Medicaid Paid Amount (excludes outliers with Total Medicaid Paid Amount > $2 million)
File Type	CIP
Measure ID	EXP-1-013-4
Measure Type	Average
Content area	EXP

Validation

Validation Type	Longitudinal and Inferential

Measure Priority

Measure Priority	Medium
Focus Area	N/A
Category	Expenditures

Claim Information

Claim Type	Medicaid,FFS
Adjustment Type	Original
Crossover Type	Non-Crossover

Thresholds

Minimum	2000
Maximum	12000
TA Minimun	1500
TA Maximum	12000
Longitudinal Threshold	0.15
For TA (for including in compliance training)	TA- Inferential
For TA (Longitudinal)	No

Data Elements

DD Data Element	TOT-MEDICAID-PAID-AMT
DD Data Element Number	CIP114

Annotation	Calculate the average amount paid (excluding outliers with Medicaid Amount Paid > $2 million) for Medicaid FFS: original, non-crossover, paid IP claims
Specification	STEP 1: Active non-duplicate paid IP claims during report month Define the IP claims universe at the header level that satisfy the following criteria: 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. STEP 2: Medicaid FFS Payment: Original, Non-Crossover, Paid Claims Of the claims that meet the criteria from STEP 1, further restrict them by the following criteria: 1. TYPE-OF-CLAIM = "1" 2. ADJUSTMENT-IND = "0" 3. CROSSOVER-INDICATOR = "0" or is missing STEP 3: Restrict claims with paid amounts less than $2,000,000 Of the records that meet the criteria from STEP 2, further restrict them to those with: 1. TOT-MEDICAID-PAID-AMT< 2,000,000 STEP 4: Average Of the records that meet the criteria in STEP 3, take the average of TOT-MEDICAID-PAID-AMT

Annotation

Calculate the average amount paid (excluding outliers with Medicaid Amount Paid > $2 million) for Medicaid FFS: original, non-crossover, paid IP claims

Specification

STEP 1: Active non-duplicate paid IP claims during report month

Define the IP claims universe at the header level that satisfy the following criteria:

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.

STEP 2: Medicaid FFS Payment: Original, Non-Crossover, Paid Claims

Of the claims that meet the criteria from STEP 1, further restrict them by the following criteria:

1. TYPE-OF-CLAIM = "1"

2. ADJUSTMENT-IND = "0"

3. CROSSOVER-INDICATOR = "0" or is missing

STEP 3: Restrict claims with paid amounts less than $2,000,000

Of the records that meet the criteria from STEP 2, further restrict them to those with:

1. TOT-MEDICAID-PAID-AMT< 2,000,000

STEP 4: Average

Of the records that meet the criteria in STEP 3, take the average of TOT-MEDICAID-PAID-AMT