MCR-21-003-2

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TMSIS Dataguide

Medicaid.gov

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MCR-21-003-2

Data Quality Measure

Last updated

Key Information

Measure Name	% of claim lines with TYPE-OF-SERVICE = 12, 29, 15, 2, 61, 28, 41 where Servicing Provider Number = Billing Provider Number
File Type	COT
Measure ID	MCR-21-003-2
Measure Type	Claims Percentage
Content area	MCR MULTI PRO

Validation

Validation Type	Inferential

Measure Priority

Measure Priority	Medium
Focus Area	Managed care
Category	Utilization

Claim Information

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

Thresholds

Minimum	0.01
Maximum	0.7
TA Minimun	0.0001
TA Maximum	0.8
Longitudinal Threshold	N/A
For TA (for including in compliance training)	TA- Inferential
For TA (Longitudinal)	No

Data Elements

DD Data Element	TYPE-OF-SERVICE • BILLING-PROV-NUM • SERVICING-PROV-NUM
DD Data Element Number	COT186 • COT112 • COT189

Annotation

Percentage of unique Medicaid Encounter: original, non-crossover, paid OT claims for TYPE-OF-SERVICE = 12, 29, 15, 2, 61, 28, 41 that have the same service provider ID and billing provider ID

Specification

STEP 1: Active non-duplicate paid OT claims during report month

Define 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 month

2. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing

3. CLAIM-DENIED-INDICATOR is not equal to "0" or is missing

4. TYPE-OF-CLAIM is not equal to "Z" or is missing

5. CLAIM-STATUS is not equal to ("26","026","87","087","542","585", "654") or is missing

6. 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 month

2. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing

3. 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 Encounter: Original, Non-crossover, Paid Claims

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

1. TYPE-OF-CLAIM = "3"

2. ADJUSTMENT-IND = "0"

3. CROSSOVER-INDICATOR = "0" or is missing

STEP 3: Type of service

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

1. TYPE-OF-SERVICE = "012"or "029" or "015" "002" or "061" or "028" or "041"

STEP 4: Same service provider ID and billing provider ID

Of the claims that meet the criteria from STEP 3, further restrict them by the following criteria:

1. SERVICING-PROV-NUM = BILLING-PROV-NUM

STEP 5: Calculate the percentage for the measure

Divide the count of claims from STEP 4 by the count of claims from STEP 3

Published Date	Data Guide Version	DQM	Action	Field	Before	After
08/13/2025	4.0.16	MCR-21-003-2	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 Encounter: 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 = "3"2. ADJUSTMENT-IND = "0" 3. CROSSOVER-INDICATOR = "0" or is missingSTEP 3: Type of serviceOf the claims that meet the criteria from STEP 2, further restrict them by the following criteria: 1. TYPE-OF-SERVICE = "012"or "029" or "015" "002" or "061" or "028" or "041"STEP 4: Same service provider ID and billing provider IDOf the claims that meet the criteria from STEP 3, further restrict them by the following criteria:1. SERVICING-PROV-NUM = BILLING-PROV-NUMSTEP 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 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 Encounter: 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 = "3"2. ADJUSTMENT-IND = "0" 3. CROSSOVER-INDICATOR = "0" or is missingSTEP 3: Type of serviceOf the claims that meet the criteria from STEP 2, further restrict them by the following criteria: 1. TYPE-OF-SERVICE = "012"or "029" or "015" "002" or "061" or "028" or "041"STEP 4: Same service provider ID and billing provider IDOf the claims that meet the criteria from STEP 3, further restrict them by the following criteria:1. SERVICING-PROV-NUM = BILLING-PROV-NUMSTEP 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	MCR-21-003-2	ADD	N/A		Created