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TMSIS Dataguide Medicaid.gov

Version:

3.39.0

MCR-13-006_1-18

Data Quality Measure
Last updated

Key Information

Measure Name % of PCCM capitation payment records with a non-missing plan ID that do not have a corresponding managed care participation PCCM plan
File Type Multiple Files
Measure ID MCR-13-006_1-18
Measure Type Non-Claims Percentage
Content area MCR

Validation

Validation Type Inferential

Measure Priority

Measure Priority Medium
Focus Area Managed care
Category Expenditures

Claim Information

Claim Type N/A
Adjustment Type Original
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 MANAGED-CARE-PLAN-TYPE • MSIS-IDENTIFICATION-NUM • MSIS-IDENTIFICATION-NUM • PAYEE-MCR-PLAN-TYPE • PAYEE-ID • MANAGED-CARE-PLAN-ID • PAYEE-ID-TYPE
DD Data Element Number ELG193 • FTX042 • ELG191 • FTX036 • FTX033 • ELG192 • FTX034

Annotation Calculate the percentage of PCCM capitation payment Financial Transaction records with a non-missing plan ID that do not have a corresponding managed care participation PCCM plan
Specification STEP 1: Active non-duplicate paid individual capitation payment financial transactions during report month

Define the FTX universe for the FTX0002 table by keeping active records that satisfy the following criteria:

1. Reporting Period from the filename = DQ report month

2. No Duplicates: Duplicates are dropped at the table level, if the following four data elements are the same: ICN-ORIG, ICN-ADJ, PAYMENT-OR-RECOUPMENT-DATE, and ADJUSTMENT-IND.



STEP 2: Managed Care Plan Payee ID Type

Of the records that meet the criteria from STEP 1, further restrict them by the following criteria:

1. PAYEE-MCR-PLAN-TYPE = "02" or "03"

2. PAYEE-ID-TYPE = "02"or "05" or "06"



STEP 3: Non-missing Payee ID

Of the records that meet the criteria from STEP 2, further restrict them by the following criteria:

1. PAYEE-ID is not missing



STEP 4: Enrolled on the last day of DQ report month

Define the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:

1. ENROLLMENT-EFF-DATE <= last day of the DQ report month

2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing

3. MSIS-IDENTIFICATION-NUM is not missing



STEP 5: Managed care enrollment on the last day of DQ report month

Of the MSIS-IDs that meet the criteria from STEP 4, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:

1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month

2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missing

OR

1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing

2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missing



STEP 6: No managed care participation PCCM plan

Of the records that meet the criteria from STEP 3, further restrict them by attempting to merge them with the data from STEP 5 and keeping those that satisfy the following criteria:

1a. PAYEE-ID = MANAGED-CARE-PLAN-ID

2a. MSIS-IDENTIFICATION-NUM matches

3a. MANAGED-CARE-PLAN-TYPE does NOT equal "02" or "03" for any records where 1a and 2a are satisfied

OR

It is not the case that:

1b. PAYEE-ID = MANAGED-CARE-PLAN-ID

2b. MSIS-IDENTIFICATION-NUM matches



STEP 7: Calculate the percentage for the measure

Divide the count of records from STEP 6 by the count of records from STEP 3