FFS-5-015-1

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TMSIS Dataguide

Medicaid.gov

Version:

FFS-5-015-1

Data Quality Measure

Last updated

Key Information

Measure Name	% of claim headers with TYPE-OF-SERVICE = 09 (nursing facility services age 21+) without nursing facility days
File Type	CLT
Measure ID	FFS-5-015-1
Measure Type	Claims Percentage
Content area	FFS

Validation

Validation Type	Longitudinal and Inferential

Measure Priority

Measure Priority	Medium
Focus Area	N/A
Category	Utilization

Claim Information

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

Thresholds

Minimum	0
Maximum	0.4
TA Minimun	0
TA Maximum	0.4
Longitudinal Threshold	0.15
For TA (for including in compliance training)	TA- Inferential
For TA (Longitudinal)	No

Data Elements

DD Data Element	NURSING-FACILITY-DAYS • TYPE-OF-SERVICE
DD Data Element Number	CLT149 • CLT211

Annotation	N/A
Specification	N/A

Published Date	Data Guide Version	DQM	Action	Field	Before	After
11/20/2025	4.0.22	FFS-5-015-1	UPDATE	Annotation	Percentage of Medicaid FFS: original, non-crossover, paid LT claims with nursing facility services age 21+ without NF days	N/A
11/20/2025	4.0.22	FFS-5-015-1	UPDATE	Specification	STEP 1: Active non-duplicate LT claims during DQ report monthDefine the LT claims universe at the header level by importing both headers and lines 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.STEP 2: Medicaid 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 = "1"2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "0" or is missingSTEP 3: Nursing facility services age 21+Of the claims that meet the criteria from STEP 2, select records where 1. TYPE-OF-SERVICE = "009"STEP 4: No NF daysOf the claims that meet the criteria from STEP 3, further restrict them by the following criteria:1. NURSING-FACILITY-DAYS = "0" or missingSTEP 5: Calculate the percentage for the measureDivide the count of claims from STEP 4 by the count of claims from STEP 3	N/A
08/13/2025	4.0.16	FFS-5-015-1	UPDATE	Specification	STEP 1: Active non-duplicate LT claims during DQ report monthDefine the LT claims universe at the header level by importing both headers and lines 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-ADJSTMT-IND.4. Lines merge to a header using ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND=LINE-ADJSTMT-IND.STEP 2: Medicaid 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 = "1"2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "0" or is missingSTEP 3: Nursing facility services age 21+Of the claims that meet the criteria from STEP 2, select records where 1. TYPE-OF-SERVICE = "009"STEP 4: No NF daysOf the claims that meet the criteria from STEP 3, further restrict them by the following criteria:1. NURSING-FACILITY-DAYS = "0" or missingSTEP 5: Calculate the percentage for the measureDivide the count of claims from STEP 4 by the count of claims from STEP 3	STEP 1: Active non-duplicate LT claims during DQ report monthDefine the LT claims universe at the header level by importing both headers and lines 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.STEP 2: Medicaid 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 = "1"2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "0" or is missingSTEP 3: Nursing facility services age 21+Of the claims that meet the criteria from STEP 2, select records where 1. TYPE-OF-SERVICE = "009"STEP 4: No NF daysOf the claims that meet the criteria from STEP 3, further restrict them by the following criteria:1. NURSING-FACILITY-DAYS = "0" or missingSTEP 5: Calculate the percentage for the measureDivide the count of claims from STEP 4 by the count of claims from STEP 3
04/24/2025	4.0.7	FFS-5-015-1	ADD	N/A		Created