FFS-52-007-7

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TMSIS Dataguide

Medicaid.gov

Version:

FFS-52-007-7

Data Quality Measure

Last updated

Key Information

Measure Name	% of claim lines where TYPE-OF-BILL does not begin with 03, 07, 08, 012, 013, 014, 022, 023, 024
File Type	COT
Measure ID	FFS-52-007-7
Measure Type	Claims Percentage
Content area	FFS

Validation

Validation Type	Inferential

Measure Priority

Measure Priority	High
Focus Area	N/A
Category	Utilization

Claim Information

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

Thresholds

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

Data Elements

DD Data Element	TYPE-OF-BILL
DD Data Element Number	COT038

Annotation	N/A
Specification	N/A

Published Date	Data Guide Version	DQM	Action	Field	Before	After
11/20/2025	4.0.22	FFS-52-007-7	UPDATE	Annotation	Calculate the percent of Medicaid and S-CHIP: FFS, original and adjustment, paid OT claims where type of bill does not begin with a value normally found on the OT file	N/A
11/20/2025	4.0.22	FFS-52-007-7	UPDATE	Specification	STEP 1: Active non-duplicate paid OT claims during report monthDefine the OT claims universe at the line 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 and S-CHIP FFS: Original and Adjustment, 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" STEP 3: Non-missing type of billOf the claims that meet the criteria from STEP 2, restrict to non-missing TYPE-OF-BILLSTEP 4: Count of claims with an invalid type of billOf the claims that meet the criteria from STEP 3, count claims where TYPE-OF-BILL does not begin with “03”or “07”or “08”or “012”or “013”or “014”or “022”or “023”or “024”STEP 5: Calculate percentDivide the count from STEP 4 by the count from STEP 3	N/A
08/13/2025	4.0.16	FFS-52-007-7	UPDATE	Specification	STEP 1: Active non-duplicate paid OT claims during report monthDefine the OT claims universe at the line 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 and S-CHIP FFS: Original and Adjustment, 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" STEP 3: Non-missing type of billOf the claims that meet the criteria from STEP 2, restrict to non-missing TYPE-OF-BILLSTEP 4: Count of claims with an invalid type of billOf the claims that meet the criteria from STEP 3, count claims where TYPE-OF-BILL does not begin with “03”or “07”or “08”or “012”or “013”or “014”or “022”or “023”or “024”STEP 5: Calculate percentDivide the count from STEP 4 by the count from STEP 3	STEP 1: Active non-duplicate paid OT claims during report monthDefine the OT claims universe at the line 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 and S-CHIP FFS: Original and Adjustment, 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" STEP 3: Non-missing type of billOf the claims that meet the criteria from STEP 2, restrict to non-missing TYPE-OF-BILLSTEP 4: Count of claims with an invalid type of billOf the claims that meet the criteria from STEP 3, count claims where TYPE-OF-BILL does not begin with “03”or “07”or “08”or “012”or “013”or “014”or “022”or “023”or “024”STEP 5: Calculate percentDivide the count from STEP 4 by the count from STEP 3
04/24/2025	4.0.7	FFS-52-007-7	ADD	N/A		Created