EXP-11-003-83

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TMSIS Dataguide

Medicaid.gov

Version:

EXP-11-003-83

Data Quality Measure

Last updated

Key Information

Measure Name	% of amount paid for claim lines with HCBS Taxonomy values beginning with 02, 04, or 08 of the amount for all claim lines with HCBS Taxonomy
File Type	COT
Measure ID	EXP-11-003-83
Measure Type	Ratio
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	0.5
Maximum	0.9
TA Minimun	0.5
TA Maximum	0.9
Longitudinal Threshold	0.3
For TA (for including in compliance training)	TA- Inferential
For TA (Longitudinal)	No

Data Elements

DD Data Element	HCBS-TAXONOMY • MEDICAID-PAID-AMT
DD Data Element Number	COT188 • COT178

Annotation	N/A
Specification	N/A

Published Date	Data Guide Version	DQM	Action	Field	Before	After
11/20/2025	4.0.22	EXP-11-003-83	UPDATE	Annotation	Calculate the percentage of Medicaid FFS: original, non-crossover, paid HCBS taxonomy claims that have HCBS taxonomy values beginning with 02, 04, or 08	N/A
11/20/2025	4.0.22	EXP-11-003-83	UPDATE	Specification	STEP 1: Active non-duplicate OT records during DQ report monthDefine the OT claims universe at the line level by importing both headers and lines that satisfy the following criteria:For Headers:1. Reporting Period from the filename = DQ report month2. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing3. CLAIM-DENIED-INDICATOR is not equal to "0" or is missing4. TYPE-OF-CLAIM is not equal to "Z" or is missing5. CLAIM-STATUS is not equal to ("26","026","87","087","542","585", "654") or is missing6. No Header Duplicates: Duplicates are dropped at the header level, if the following four data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND.For Lines:1. Reporting Period from the filename = DQ report month2. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing3. No Line Duplicates: Duplicates are dropped at the line level if the following data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, LINE-NUM-ORIG, LINE-NUM-ADJ, and LINE-ADJUSTMENT-IND.4. Lines merge to a header using ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND=LINE-ADJUSTMENT-IND.STEP 2: Medicaid FFS: Original, Non-Crossover, Paid ClaimsOf 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 missingSTEP 3: Type of serviceOf the line records that meet the criteria from STEP 2, further restrict them by the following criteria:1. HCBS-TAXONOMY starts with "02", "04", or "08"2. MEDICAID-PAID-AMT is not missingSTEP 4: Amount paid1. Of the line records that meet the criteria from STEP 3, sum MEDICAID-PAID-AMT(this will be the numerator)STEP 5: All servicesOf the line records that meet the criteria from STEP 2, further restrict them by the following criteria:1. HCBS-TAXONOMY is not missing2. MEDICAID-PAID-AMT is not missingSTEP 6: Amount paidOf the line records that meet the criteria from STEP 5, sum MEDICAID-PAID-AMT(this will be the denominator)STEP 7: Calculate percentageDivide the numerator by the denominator	N/A
08/13/2025	4.0.16	EXP-11-003-83	UPDATE	Specification	STEP 1: Active non-duplicate OT records during DQ report monthDefine the OT claims universe at the line level by importing both headers and lines that satisfy the following criteria:For Headers:1. Reporting Period from the filename = DQ report month2. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing3. CLAIM-DENIED-INDICATOR is not equal to "0" or is missing4. TYPE-OF-CLAIM is not equal to "Z" or is missing5. CLAIM-STATUS is not equal to ("26","026","87","087","542","585", "654") or is missing6. No Header Duplicates: Duplicates are dropped at the header level, if the following four data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND.For Lines:1. Reporting Period from the filename = DQ report month2. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing3. No Line Duplicates: Duplicates are dropped at the line level if the following data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, LINE-NUM-ORIG, LINE-NUM-ADJ, and LINE-ADJSTMT-IND.4. Lines merge to a header using ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND=LINE-ADJSTMT-IND.STEP 2: Medicaid FFS: Original, Non-Crossover, Paid ClaimsOf 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 missingSTEP 3: Type of serviceOf the line records that meet the criteria from STEP 2, further restrict them by the following criteria:1. HCBS-TAXONOMY starts with "02", "04", or "08"2. MEDICAID-PAID-AMT is not missingSTEP 4: Amount paid1. Of the line records that meet the criteria from STEP 3, sum MEDICAID-PAID-AMT(this will be the numerator)STEP 5: All servicesOf the line records that meet the criteria from STEP 2, further restrict them by the following criteria:1. HCBS-TAXONOMY is not missing2. MEDICAID-PAID-AMT is not missingSTEP 6: Amount paidOf the line records that meet the criteria from STEP 5, sum MEDICAID-PAID-AMT(this will be the denominator)STEP 7: Calculate percentageDivide the numerator by the denominator	STEP 1: Active non-duplicate OT records during DQ report monthDefine the OT claims universe at the line level by importing both headers and lines that satisfy the following criteria:For Headers:1. Reporting Period from the filename = DQ report month2. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing3. CLAIM-DENIED-INDICATOR is not equal to "0" or is missing4. TYPE-OF-CLAIM is not equal to "Z" or is missing5. CLAIM-STATUS is not equal to ("26","026","87","087","542","585", "654") or is missing6. No Header Duplicates: Duplicates are dropped at the header level, if the following four data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND.For Lines:1. Reporting Period from the filename = DQ report month2. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing3. No Line Duplicates: Duplicates are dropped at the line level if the following data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, LINE-NUM-ORIG, LINE-NUM-ADJ, and LINE-ADJUSTMENT-IND.4. Lines merge to a header using ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND=LINE-ADJUSTMENT-IND.STEP 2: Medicaid FFS: Original, Non-Crossover, Paid ClaimsOf 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 missingSTEP 3: Type of serviceOf the line records that meet the criteria from STEP 2, further restrict them by the following criteria:1. HCBS-TAXONOMY starts with "02", "04", or "08"2. MEDICAID-PAID-AMT is not missingSTEP 4: Amount paid1. Of the line records that meet the criteria from STEP 3, sum MEDICAID-PAID-AMT(this will be the numerator)STEP 5: All servicesOf the line records that meet the criteria from STEP 2, further restrict them by the following criteria:1. HCBS-TAXONOMY is not missing2. MEDICAID-PAID-AMT is not missingSTEP 6: Amount paidOf the line records that meet the criteria from STEP 5, sum MEDICAID-PAID-AMT(this will be the denominator)STEP 7: Calculate percentageDivide the numerator by the denominator
04/24/2025	4.0.7	EXP-11-003-83	ADD	N/A		Created