FFS-11-005-21

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TMSIS Dataguide

Medicaid.gov

Version:

FFS-11-005-21

Data Quality Measure

Last updated

Key Information

Measure Name	% of claim lines with TYPE-OF-SERVICE = 12, 2, 61, 28, 41 with diagnosis codes
File Type	COT
Measure ID	FFS-11-005-21
Measure Type	Claims Percentage
Content area	FFS

Validation

Validation Type	Longitudinal and Inferential

Measure Priority

Measure Priority	High
Focus Area	N/A
Category	Utilization

Claim Information

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

Thresholds

Minimum	0.95
Maximum	1
TA Minimun	0.95
TA Maximum	1
Longitudinal Threshold	0.15
For TA (for including in compliance training)	TA- Inferential
For TA (Longitudinal)	No

Data Elements

DD Data Element	TYPE-OF-SERVICE • DIAGNOSIS-CODE
DD Data Element Number	COT186 • COT284

Annotation	N/A
Specification	N/A

Published Date	Data Guide Version	DQM	Action	Field	Before	After
11/20/2025	4.0.22	FFS-11-005-21	UPDATE	Annotation	Percentage of unique S-CHIP FFS: original, non-crossover, paid OT claims with TYPE-OF-SERVICE = 12, 2, 61, 28, 41 with DX Codes	N/A
11/20/2025	4.0.22	FFS-11-005-21	UPDATE	Specification	STEP 1: Active non-duplicate paid OT claims during report monthDefine the OT claims universe at the line level by importing headers, lines, and DX segments 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.For DX segments:1. DX segments merge to a header using ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND.2. No DX Duplicates: Duplicates are dropped at the diagnosis level, if the following seven data elements are the same: SUBMITTING-STATE, ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, ADJUSTMENT-IND, DIAGNOSIS-CODE, and DIAGNOSIS-SEQUENCE-NUMBER.STEP 2: S-CHIP 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 = "A"2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "0" or is missingSTEP 3: Type of serviceOf the claim lines that meet the criteria from STEP 2, further restrict them by the following criteria: 1. TYPE-OF-SERVICE = “012” or “002” or “061” or "028" or "041"STEP 4: Non-missing diagnosis codeOf the DX segments that meet the criteria from STEP 1, select records where 1. DIAGNOSIS-CODE value is not missing.STEP 5: Link claim lines to claim DX recordsMerge the lines from STEP 3 with the DX records from STEP 4 by header.STEP 6: Drop lines without diagnosis codesOf the claim lines from STEP 5, keep only lines linked to a DX record from STEP 4STEP 7: Calculate the percentage for the measureDivide the count of claim lines from STEP 6 by the count of claim lines from STEP 3	N/A
08/13/2025	4.0.16	FFS-11-005-21	UPDATE	Specification	STEP 1: Active non-duplicate paid OT claims during report monthDefine the OT claims universe at the line level by importing headers, lines, and DX segments 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.For DX segments:1. DX segments merge to a header using ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND.2. No DX Duplicates: Duplicates are dropped at the diagnosis level, if the following seven data elements are the same: SUBMITTING-STATE, ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, ADJUSTMENT-IND, DIAGNOSIS-TYPE-CODE, and DIAGNOSIS-SEQUENCE-NUMBER.STEP 2: S-CHIP 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 = "A"2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "0" or is missingSTEP 3: Type of serviceOf the claim lines that meet the criteria from STEP 2, further restrict them by the following criteria: 1. TYPE-OF-SERVICE = “012” or “002” or “061” or "028" or "041"STEP 4: Non-missing diagnosis codeOf the DX segments that meet the criteria from STEP 1, select records where 1. DIAGNOSIS-CODE value is not missing.STEP 5: Link claim lines to claim DX recordsMerge the lines from STEP 3 with the DX records from STEP 4 by header.STEP 6: Drop lines without diagnosis codesOf the claim lines from STEP 5, keep only lines linked to a DX record from STEP 4STEP 7: Calculate the percentage for the measureDivide the count of claim lines from STEP 6 by the count of claim lines from STEP 3	STEP 1: Active non-duplicate paid OT claims during report monthDefine the OT claims universe at the line level by importing headers, lines, and DX segments 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.For DX segments:1. DX segments merge to a header using ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND.2. No DX Duplicates: Duplicates are dropped at the diagnosis level, if the following seven data elements are the same: SUBMITTING-STATE, ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, ADJUSTMENT-IND, DIAGNOSIS-CODE, and DIAGNOSIS-SEQUENCE-NUMBER.STEP 2: S-CHIP 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 = "A"2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "0" or is missingSTEP 3: Type of serviceOf the claim lines that meet the criteria from STEP 2, further restrict them by the following criteria: 1. TYPE-OF-SERVICE = “012” or “002” or “061” or "028" or "041"STEP 4: Non-missing diagnosis codeOf the DX segments that meet the criteria from STEP 1, select records where 1. DIAGNOSIS-CODE value is not missing.STEP 5: Link claim lines to claim DX recordsMerge the lines from STEP 3 with the DX records from STEP 4 by header.STEP 6: Drop lines without diagnosis codesOf the claim lines from STEP 5, keep only lines linked to a DX record from STEP 4STEP 7: Calculate the percentage for the measureDivide the count of claim lines from STEP 6 by the count of claim lines from STEP 3
04/24/2025	4.0.7	FFS-11-005-21	ADD	N/A		Created