EXP-16-001-13

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Measure Name	Sum of Total Medicaid Paid Amount
File Type	CRX
Measure ID	EXP-16-001-13
Measure Type	Sum
Content area	EXP

Validation Type	Longitudinal

Measure Priority	Medium
Focus Area	N/A
Category	Expenditures

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

Minimum	N/A
Maximum	N/A
TA Minimun
TA Maximum
Longitudinal Threshold	0.5
For TA (for including in compliance training)	TA- Longitudinal
For TA (Longitudinal)	Yes

DD Data Element	TOT-MEDICAID-PAID-AMT
DD Data Element Number	CRX041

Annotation	N/A
Specification	N/A

Published Date	Data Guide Version	DQM	Action	Field	Before	After
11/20/2025	4.0.22	EXP-16-001-13	UPDATE	Annotation	Calculate the sum of the total Medicaid amount paid for Medicaid FFS: original, non-crossover, paid RX claims	N/A
11/20/2025	4.0.22	EXP-16-001-13	UPDATE	Specification	STEP 1: Active non-duplicate RX claims during DQ report monthDefine the RX claims universe at the header level that satisfy the following criteria:1. Reporting Period for 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.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: Sum the total Medicaid paid amountSum the TOT-MEDICAID-PAID-AMT of the records which meet the criteria from STEP 2	N/A
04/24/2025	4.0.7	EXP-16-001-13	ADD	N/A		Created

EXP-16-001-13

Key Information

Validation

Measure Priority

Claim Information

Thresholds

Data Elements