EXP-31-001-1

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Measure Name	% of claim headers with Total Medicaid Paid Amount = $0 or missing
File Type	CIP
Measure ID	EXP-31-001-1
Measure Type	Claims percentage
Content area	MCR MULTI EXP

Validation Type	Inferential

Measure Priority	High
Focus Area	Managed care
Category	Expenditures

Claim Type	CHIP,Enc
Adjustment Type	Original
Crossover Type	Non-Crossover

Minimum	0
Maximum	0.05
TA Minimun	0
TA Maximum	0.1
Longitudinal Threshold	0.2
For TA (for including in compliance training)	TA- Inferential
For TA (Longitudinal)	No

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

Annotation	N/A
Specification	N/A

Published Date	Data Guide Version	DQM	Action	Field	Before	After
11/20/2025	4.0.22	EXP-31-001-1	UPDATE	Annotation	Calculate the percentage of S-CHIP Encounter: original, non-crossover, paid IP claims where total Medicaid paid amount is equal to $0 or missing	N/A
11/20/2025	4.0.22	EXP-31-001-1	UPDATE	Specification	STEP 1: Active non-duplicate paid IP claims during report monthDefine the IP claims universe at the header level that satisfy the following criteria: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.STEP 2: S-CHIP Encounter: 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 = "C"2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "0" or is missingSTEP 3: Exclude sub-capitation encountersOf the claims that meet the criteria from STEP 2, further restrict them by the following criteria:1. SOURCE-LOCATION is NOT equal to "22" or "23"STEP 4: Total Medicaid paid $0 or missingOf the claims that meet the criteria from STEP 3, restrict to claims that meet the following criteria:1. TOT-MEDICAID-PAID-AMT = "0" or is missingSTEP 5: Calculate percentageDivide the number of claims from STEP 4 by the number of claims from STEP 3.	N/A
04/24/2025	4.0.7	EXP-31-001-1	ADD	N/A		Created

EXP-31-001-1

Key Information

Validation

Measure Priority

Claim Information

Thresholds

Data Elements