FFS-45-001-1

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Measure Name	% of crossover claim headers where Total Medicare Deductible Amount and Total Medicare Coinsurance Amount do not sum to Total Medicaid Paid Amount
File Type	COT
Measure ID	FFS-45-001-1
Measure Type	Claims percentage
Content area	FFS

Validation Type	Inferential

Measure Priority	Medium
Focus Area	N/A
Category	Expenditures

Claim Type	Medicaid,FFS
Adjustment Type	All Adjustment Types
Crossover Type	Crossover

Minimum	0
Maximum	0.05
TA Minimun	0
TA Maximum	0.05
Longitudinal Threshold	N/A
For TA (for including in compliance training)	TA- Inferential
For TA (Longitudinal)	No

DD Data Element	TOT-MEDICARE-COINS-AMT • TOT-MEDICAID-PAID-AMT • TOT-MEDICARE-DEDUCTIBLE-AMT
DD Data Element Number	COT053 • COT050 • COT052

Annotation	N/A
Specification	N/A

Published Date	Data Guide Version	DQM	Action	Field	Before	After
11/20/2025	4.0.22	FFS-45-001-1	UPDATE	Annotation	The percentage of Medicaid FFS: original and adjustment, crossover, paid OT claims where the sum of the Medicare deductible amount and Medicare coinsurance amount does not equal total Medicaid paid amount	N/A
11/20/2025	4.0.22	FFS-45-001-1	UPDATE	Specification	STEP 1: Active non-duplicate paid OT claims during report monthDefine the OT 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: Medicaid FFS: Original and Adjustment, 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. CROSSOVER-INDICATOR = "1"STEP 3: Total Medicare deductible and coinsurance amountOf the claims that meet the criteria from STEP 2, calculate the sum of TOT-MEDICARE-COINS-AMT* and TOT-MEDICARE-DEDUCTIBLE-AMTNote: Missing values are converted to 0 before calculating the sumSTEP 4: Claims where total Medicare deductibles and coinsurance amounts do not equal Medicaid paid amountsCount the number of claims where the sum from STEP 3 does NOT equal TOT-MEDICAID-PAID-AMTNote: Missing values are converted to 0 before comparisonSTEP 5: Calculate the percentage for the measureDivide the count from STEP 4 by the count from STEP 2	N/A
04/24/2025	4.0.7	FFS-45-001-1	ADD	N/A		Created

FFS-45-001-1

Key Information

Validation

Measure Priority

Claim Information

Thresholds

Data Elements