EXP-11-161_1-164

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TMSIS Dataguide

Medicaid.gov

Version:

EXP-11-161_1-164

Data Quality Measure

Last updated

Key Information

Measure Name	% of claim lines on claims where Payment Level Indicator = 2 with Medicaid Paid Amount = $0 or missing
File Type	COT
Measure ID	EXP-11-161_1-164
Measure Type	Claims Percentage
Content area	EXP

Validation

Validation Type	Longitudinal and Inferential

Measure Priority

Measure Priority	High
Focus Area	N/A
Category	Expenditures

Claim Information

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

Thresholds

Minimum	0
Maximum	0.3
TA Minimun	0
TA Maximum	0.3
Longitudinal Threshold	N/A
For TA (for including in compliance training)	TA- Inferential
For TA (Longitudinal)	No

Data Elements

DD Data Element	MEDICAID-PAID-AMT • PAYMENT-LEVEL-IND
DD Data Element Number	COT178 • COT068

Annotation	N/A
Specification	N/A

Published Date	Data Guide Version	DQM	Action	Field	Before	After
11/20/2025	4.0.22	EXP-11-161_1-164	UPDATE	Annotation	Calculate the percentage of Medicaid FFS: original, non-crossover, paid OT claims billed at the line level that have Medicaid paid amount equal to $0 or missing	N/A
11/20/2025	4.0.22	EXP-11-161_1-164	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: Payment at the line levelOf the claims that meet the criteria from STEP 2, count records where:1. PAYMENT-LEVEL-IND = "2"STEP 4: Medicaid paid $0 or missingOf the claims that meet the criteria from STEP 3, select records with 1. MEDICAID-PAID-AMT = "0" or is missingSTEP 5: Calculate the percentage for the measureDivide the count of claims from STEP 4 by the count of claims from STEP 3	N/A
10/07/2025	4.0.19	EXP-11-161_1-164	UPDATE	Grace period expiration date	None	2024-03-11
08/13/2025	4.0.16	EXP-11-161_1-164	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: Payment at the line levelOf the claims that meet the criteria from STEP 2, count records where:1. PAYMENT-LEVEL-IND = "2"STEP 4: Medicaid paid $0 or missingOf the claims that meet the criteria from STEP 3, select records with 1. MEDICAID-PAID-AMT = "0" or is missingSTEP 5: Calculate the percentage for the measureDivide the count of claims from STEP 4 by the count of claims from STEP 3	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: Payment at the line levelOf the claims that meet the criteria from STEP 2, count records where:1. PAYMENT-LEVEL-IND = "2"STEP 4: Medicaid paid $0 or missingOf the claims that meet the criteria from STEP 3, select records with 1. MEDICAID-PAID-AMT = "0" or is missingSTEP 5: Calculate the percentage for the measureDivide the count of claims from STEP 4 by the count of claims from STEP 3
04/24/2025	4.0.7	EXP-11-161_1-164	ADD	N/A		Created