EXP-11-082-5

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TMSIS Dataguide

Medicaid.gov

Version:

EXP-11-082-5

Data Quality Measure

Last updated

Key Information

Measure Name	Average Medicaid Paid Amount for HCBS Program (exclude outliers with Medicaid Paid Amount > $200,000)
File Type	COT
Measure ID	EXP-11-082-5
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	100
Maximum	4000
TA Minimun	90
TA Maximum	4500
Longitudinal Threshold	0.25
For TA (for including in compliance training)	TA- Inferential
For TA (Longitudinal)	No

Data Elements

DD Data Element	MEDICAID-PAID-AMT • HCBS-SERVICE-CODE
DD Data Element Number	COT178 • COT187

Annotation

Calculate the average amount paid (excluding outliers with Medicaid Amount Paid > $200,000) for Medicaid FFS: original, non-crossover, paid OT claims for HCBS program

Specification

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

Define 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 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, ADJUDICATION-DATE, and ADJUSTMENT-IND=LINE-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: HCBS service code

Of the records that meet the criteria from STEP 2, select records with HCBS-SERVICE-CODE is not missing

STEP 4: Restrict claims with paid amounts less than $200,000

Of the records that meet the criteria from STEP 3, further restrict them to those with MEDICAID-PAID-AMT > 0 and MEDICAID-PAID-AMT < $200,000

STEP 5: Average

1. Of the line records that meet the criteria in STEP 4, take the average of MEDICAID-PAID-AMT

Published Date	Data Guide Version	DQM	Action	Field	Before	After
08/13/2025	4.0.16	EXP-11-082-5	UPDATE	Specification	STEP 1: Active non-duplicate paid OT claims during 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 Payment: 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: HCBS service codeOf the records that meet the criteria from STEP 2, select records with HCBS-SERVICE-CODE is not missingSTEP 4: Restrict claims with paid amounts less than $200,000Of the records that meet the criteria from STEP 3, further restrict them to those with MEDICAID-PAID-AMT > 0 and MEDICAID-PAID-AMT < $200,000STEP 5: Average1. Of the line records that meet the criteria in STEP 4, take the average of MEDICAID-PAID-AMT	STEP 1: Active non-duplicate paid OT claims during 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 Payment: 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: HCBS service codeOf the records that meet the criteria from STEP 2, select records with HCBS-SERVICE-CODE is not missingSTEP 4: Restrict claims with paid amounts less than $200,000Of the records that meet the criteria from STEP 3, further restrict them to those with MEDICAID-PAID-AMT > 0 and MEDICAID-PAID-AMT < $200,000STEP 5: Average1. Of the line records that meet the criteria in STEP 4, take the average of MEDICAID-PAID-AMT
04/24/2025	4.0.7	EXP-11-082-5	ADD	N/A		Created