EXP-40-001-1

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Measure Name	% of claim headers with Total Medicaid Paid Amount = $0 or missing
File Type	COT
Measure ID	EXP-40-001-1
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	Crossover

Minimum	0
Maximum	0.3
TA Minimun	0
TA Maximum	0.4
Longitudinal Threshold	0.1
For TA (for including in compliance training)	TA- Inferential
For TA (Longitudinal)	No

DD Data Element	TOT-MEDICAID-PAID-AMT
DD Data Element Number	COT050

Annotation	N/A
Specification	N/A

Published Date	Data Guide Version	DQM	Action	Field	Before	After
11/20/2025	4.0.22	EXP-40-001-1	UPDATE	Annotation	Calculate the percentage of S-CHIP Encounter: original, crossover, paid OT claims where total Medicaid paid amount is equal to $0 or missing	N/A
11/20/2025	4.0.22	EXP-40-001-1	UPDATE	Specification	STEP 1: Active non-duplicate OT records during DQ report monthDefine the OT records 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: S-CHIP Encounter: Original, 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 = "1"STEP 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-40-001-1	ADD	N/A		Created

EXP-40-001-1

Key Information

Validation

Measure Priority

Claim Information

Thresholds

Data Elements