MCR-59-004-16

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TMSIS Dataguide

Medicaid.gov

Version:

MCR-59-004-16

Data Quality Measure

Last updated

Key Information

Measure Name	% of claim headers with PAYMENT-LEVEL-IND = 2 where the sum of Medicaid Paid Amount from the lines does not equal Total Medicaid Paid Amount from the header
File Type	CRX
Measure ID	MCR-59-004-16
Measure Type	Claims Percentage
Content area	MCR

Validation

Validation Type	Inferential

Measure Priority

Measure Priority	High
Focus Area	Managed care
Category	Expenditures

Claim Information

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

Thresholds

Minimum	0
Maximum	0.01
TA Minimun	0
TA Maximum	0.01
Longitudinal Threshold	N/A
For TA (for including in compliance training)	TA- Inferential
For TA (Longitudinal)	No

Data Elements

DD Data Element	MEDICAID-PAID-AMT • TOT-MEDICAID-PAID-AMT
DD Data Element Number	CRX125 • CRX041

Annotation	N/A
Specification	N/A

Published Date	Data Guide Version	DQM	Action	Field	Before	After
11/20/2025	4.0.22	MCR-59-004-16	UPDATE	Annotation	Calculate the percentage of Medicaid and S-CHIP Encounter: original, paid RX claims that are paid at the line level where the sum of Medicaid paid amount from the lines does not equal the total Medicaid paid amount from the header	N/A
11/20/2025	4.0.22	MCR-59-004-16	UPDATE	Specification	STEP 1: Active non-duplicate paid RX claims during report monthDefine the RX 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 and S-CHIP Encounter: Original, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "3" or "C"2. ADJUSTMENT-IND = "0" STEP 3: Exclude sub-capitation encountersOf the claims that meet the criteria from STEP 2, further restrict them by the following criteria:1. SOURCE-LOCATION is NOT equal to "22" or "23"STEP 4: Exclude childless headersOf the claim headers that meet the criteria from STEP 3, drop all headers that do not merge to at least one lineSTEP 5: Claims paid at the line levelOf claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. PAYMENT-LEVEL-IND = "2"STEP 6: Sum Medicaid paid amount from the claim linesOf the claim lines that meet the criteria from STEP 3, sum the MEDICAID-PAID-AMT values to the header levelNote: Missing values are converted to 0 before calculating the sumSTEP 7: Sum does not match total Medicaid paid amountKeep the claims where the sum from STEP 6 does NOT equal the TOT-MEDICAID-PAID-AMT from the header recordNote: Missing values are converted to 0 before comparisonSTEP 8: Calculate the percentage for the measureDivide the count of claims from STEP 7 by the count of claims from STEP 5.	N/A
10/07/2025	4.0.19	MCR-59-004-16	UPDATE	Grace period expiration date	None	2022-10-31
08/13/2025	4.0.16	MCR-59-004-16	UPDATE	Specification	STEP 1: Active non-duplicate paid RX claims during report monthDefine the RX 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 and S-CHIP Encounter: Original, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "3" or "C"2. ADJUSTMENT-IND = "0" STEP 3: Exclude sub-capitation encountersOf the claims that meet the criteria from STEP 2, further restrict them by the following criteria:1. SOURCE-LOCATION is NOT equal to "22" or "23"STEP 4: Exclude childless headersOf the claim headers that meet the criteria from STEP 3, drop all headers that do not merge to at least one lineSTEP 5: Claims paid at the line levelOf claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. PAYMENT-LEVEL-IND = "2"STEP 6: Sum Medicaid paid amount from the claim linesOf the claim lines that meet the criteria from STEP 3, sum the MEDICAID-PAID-AMT values to the header levelNote: Missing values are converted to 0 before calculating the sumSTEP 7: Sum does not match total Medicaid paid amountKeep the claims where the sum from STEP 6 does NOT equal the TOT-MEDICAID-PAID-AMT from the header recordNote: Missing values are converted to 0 before comparisonSTEP 8: Calculate the percentage for the measureDivide the count of header claims from STEP 7 by the count of header claims from STEP 5.	STEP 1: Active non-duplicate paid RX claims during report monthDefine the RX 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 and S-CHIP Encounter: Original, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "3" or "C"2. ADJUSTMENT-IND = "0" STEP 3: Exclude sub-capitation encountersOf the claims that meet the criteria from STEP 2, further restrict them by the following criteria:1. SOURCE-LOCATION is NOT equal to "22" or "23"STEP 4: Exclude childless headersOf the claim headers that meet the criteria from STEP 3, drop all headers that do not merge to at least one lineSTEP 5: Claims paid at the line levelOf claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. PAYMENT-LEVEL-IND = "2"STEP 6: Sum Medicaid paid amount from the claim linesOf the claim lines that meet the criteria from STEP 3, sum the MEDICAID-PAID-AMT values to the header levelNote: Missing values are converted to 0 before calculating the sumSTEP 7: Sum does not match total Medicaid paid amountKeep the claims where the sum from STEP 6 does NOT equal the TOT-MEDICAID-PAID-AMT from the header recordNote: Missing values are converted to 0 before comparisonSTEP 8: Calculate the percentage for the measureDivide the count of claims from STEP 7 by the count of claims from STEP 5.
04/24/2025	4.0.7	MCR-59-004-16	ADD	N/A		Created