EXP-41P-001-1

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TMSIS Dataguide

Medicaid.gov

Version:

EXP-41P-001-1

Data Quality Measure

Last updated

Key Information

Measure Name	% of claim headers with Total Medicaid Paid Amount = $0 or missing, by Plan ID
File Type	CRX
Measure ID	EXP-41P-001-1
Measure Type	Claims percentage
Content area	MCR MULTI EXP
Associated Measure	EXP-41R-001-1

Validation

Validation Type	Inferential

Measure Priority

Measure Priority	N/A
Focus Area	N/A
Category	N/A

Claim Information

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

Thresholds

Minimum	0
Maximum	0.1
TA Minimun
TA Maximum
Longitudinal Threshold	N/A
For TA (for including in compliance training)	No
For TA (Longitudinal)	No

Data Elements

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-41P-001-1	UPDATE	Annotation	For each unique Plan ID, calculate the percentage of Medicaid Encounter: original, non-crossover, paid RX claims that have total Medicaid paid amount equal to $0 or missing	N/A
11/20/2025	4.0.22	EXP-41P-001-1	UPDATE	Specification	STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Managed care enrollment on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 1, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 3: Managed care plans on the last day of DQ report monthDefine the managed care plan population from segment MANAGED-CARE-MAIN-MCR00002 by keeping active records that satisfy the following criteria:1. MANAGED-CARE-MAIN-REC-EFF-DATE <= last day of the reporting month2. MANAGED-CARE-MAIN-REC-END-DATE >= last day of the reporting month OR missingSTEP 4: Active non-duplicate RX records during DQ report monthDefine the RX 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 5: Medicaid and S-CHIP Capitation Payment and Encounter: Paid ClaimsOf the claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-CLAIM = (“2” or "3" or “B” or "C")STEP 6: Define Plan_IdDefine Plan_Id as a unique list of: MANAGED-CARE-PLAN-ID from the EL file that meet the constraints in STEP 2, STATE-PLAN-ID-NUM from the MCR file that meet the constraints in STEP 3, and PLAN-ID-NUMBER from the claims files that meet the constraints in STEP 5. Also, define a blank Plan_Id for missing.STEP 7: Medicaid Encounter: Original, Non-Crossover, Paid ClaimsOf the claims that meet the criteria from STEP 5, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "3"2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "0" or is missingSTEP 8: Exclude sub-capitation encountersOf the claims that meet the criteria from STEP 7, further restrict them by the following criteria:1. SOURCE-LOCATION is NOT equal to "22" or "23"STEP 9: Total Medicaid paid $0 or missingOf the claims from STEP 8, select records where:1. TOT-MEDICAID-PAID-AMT = "0" or is missingSTEP 10: Calculate the percentage for the measureDivide the count of claims from STEP 9 by the count of claims from STEP 8STEP 11: Repeat for each Plan_IdREPEAT STEPS 7-10 for each Plan_Id identified in STEP 6	N/A
04/24/2025	4.0.7	EXP-41P-001-1	ADD	N/A		Created