FFS-49-005-5

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Measure Name	% of claim headers that have Total Medicaid Paid Amount greater than a non-zero Total Allowed Amount
File Type	CIP
Measure ID	FFS-49-005-5
Measure Type	Claims Percentage
Content area	FFS

Validation Type	Inferential

Measure Priority	High
Focus Area	N/A
Category	Expenditures

Claim Type	Medicaid,FFS or CHIP,FFS
Adjustment Type	Original
Crossover Type	All Indicators

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-ALLOWED-AMT • TOT-MEDICAID-PAID-AMT
DD Data Element Number	CIP113 • CIP114

Annotation	N/A
Specification	N/A

Published Date	Data Guide Version	DQM	Action	Field	Before	After
11/20/2025	4.0.22	FFS-49-005-5	UPDATE	Annotation	Calculate the percentage of Medicaid and S-CHIP FFS: original, paid IP claims where the total Medicaid paid amount is greater than the total allowed amount	N/A
11/20/2025	4.0.22	FFS-49-005-5	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: Medicaid and S-CHIP FFS: Original, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "1" or "A"2. ADJUSTMENT-IND = "0"STEP 3: Non-missing total Medicaid paid and allowed amountsOf the records from STEP 2, further refine the population with the following criteria: 1. TOT-MEDICAID-PAID-AMT is not missing2. TOT-ALLOWED-AMT is not missing3. TOT-ALLOWED-AMT is not equal to 0STEP 4: Total Medicaid paid is greater than total allowed Of the records from STEP 3, further refine the population with the following criteria:1. TOT-MEDICAID-PAID-AMT > TOT-ALLOWED-AMTSTEP 5: PercentageDivide the count of claims from STEP 4 by the count of claims from STEP 3	N/A
04/24/2025	4.0.7	FFS-49-005-5	ADD	N/A		Created

FFS-49-005-5

Key Information

Validation

Measure Priority

Claim Information

Thresholds

Data Elements