08/13/2025 |
4.0.16 |
MCR-59P-002-14 |
UPDATE |
Specification |
STEP 1: Enrolled on the last day of DQ report monthDefine 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 missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Managed care enrollment on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 1, 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 month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 3: Managed care plans on the last day of DQ report monthDefine the managed care plan population from segment MANAGED-CARE-MAIN-MCR00002 by keeping active records that satisfy the following criteria:1. MANAGED-CARE-MAIN-REC-EFF-DATE <= last day of the reporting month2. MANAGED-CARE-MAIN-REC-END-DATE >= last day of the reporting month OR missingSTEP 4: Active non-duplicate paid LT claims during 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 5: Medicaid and S-CHIP Capitation Payment and Encounter: Paid ClaimsOf the claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-CLAIM = (“2” or "3" or “B” or "C")STEP 6: Define Plan_IdDefine Plan_Id as a unique list of: MANAGED-CARE-PLAN-ID from the EL file that meet the constraints in STEP 2, STATE-PLAN-ID-NUM from the MCR file that meet the constraints in STEP 3, and PLAN-ID-NUMBER from the claims files that meet the constraints in STEP 5. Also, define a blank Plan_Id for missing.STEP 7: Medicaid and S-CHIP Encounter: Original, Paid ClaimsOf the claims that meet the criteria from STEP 5, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "3" or "C"2. ADJUSTMENT-IND = "0" STEP 8: Exclude sub-capitation encountersOf the claims that meet the criteria from STEP 7, further restrict them by the following criteria:1. SOURCE-LOCATION is NOT equal to "22" or "23"STEP 9: Exclude childless headersOf the claim headers that meet the criteria from STEP 8, drop all headers that do not merge to at least one lineSTEP 10: Claims paid at the line levelOf claims that meet the criteria from STEP 9, further restrict them by the following criteria:1. PAYMENT-LEVEL-IND = "2"STEP 11: Sum Medicaid paid amount from the claim linesOf the claim lines that meet the criteria from STEP 10, sum the MEDICAID-PAID-AMT values to the header level**Note: Missing values are converted to 0 before calculating the sumSTEP 12: Sum does not match total Medicaid paid amountKeep the claims where the sum from STEP 11 does NOT equal the TOT-MEDICAID-PAID-AMT from the header record**Note: Missing values are converted to 0 before comparisonSTEP 13: Calculate the percentage for the measureDivide the count of claims from STEP 12 by the count of claims from STEP 11STEP 14: Repeat for each Plan_IdREPEAT STEPS 7-13 for each Plan_Id identified in STEP 6 |
STEP 1: Enrolled on the last day of DQ report monthDefine 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 missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Managed care enrollment on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 1, 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 month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 3: Managed care plans on the last day of DQ report monthDefine the managed care plan population from segment MANAGED-CARE-MAIN-MCR00002 by keeping active records that satisfy the following criteria:1. MANAGED-CARE-MAIN-REC-EFF-DATE <= last day of the reporting month2. MANAGED-CARE-MAIN-REC-END-DATE >= last day of the reporting month OR missingSTEP 4: Active non-duplicate paid LT claims during 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 5: Medicaid and S-CHIP Capitation Payment and Encounter: Paid ClaimsOf the claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-CLAIM = (“2” or "3" or “B” or "C")STEP 6: Define Plan_IdDefine Plan_Id as a unique list of: MANAGED-CARE-PLAN-ID from the EL file that meet the constraints in STEP 2, STATE-PLAN-ID-NUM from the MCR file that meet the constraints in STEP 3, and PLAN-ID-NUMBER from the claims files that meet the constraints in STEP 5. Also, define a blank Plan_Id for missing.STEP 7: Medicaid and S-CHIP Encounter: Original, Paid ClaimsOf the claims that meet the criteria from STEP 5, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "3" or "C"2. ADJUSTMENT-IND = "0" STEP 8: Exclude sub-capitation encountersOf the claims that meet the criteria from STEP 7, further restrict them by the following criteria:1. SOURCE-LOCATION is NOT equal to "22" or "23"STEP 9: Exclude childless headersOf the claim headers that meet the criteria from STEP 8, drop all headers that do not merge to at least one lineSTEP 10: Claims paid at the line levelOf claims that meet the criteria from STEP 9, further restrict them by the following criteria:1. PAYMENT-LEVEL-IND = "2"STEP 11: Sum Medicaid paid amount from the claim linesOf the claim lines that meet the criteria from STEP 10, sum the MEDICAID-PAID-AMT values to the header level**Note: Missing values are converted to 0 before calculating the sumSTEP 12: Sum does not match total Medicaid paid amountKeep the claims where the sum from STEP 11 does NOT equal the TOT-MEDICAID-PAID-AMT from the header record**Note: Missing values are converted to 0 before comparisonSTEP 13: Calculate the percentage for the measureDivide the count of claims from STEP 12 by the count of claims from STEP 11STEP 14: Repeat for each Plan_IdREPEAT STEPS 7-13 for each Plan_Id identified in STEP 6 |
05/27/2025 |
4.0.9 |
MCR-59P-002-14 |
UPDATE |
Specification |
STEP 1: Enrolled on the last day of DQ report monthDefine 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 missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Managed care enrollment on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 1, 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 month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 3: Managed care plans on the last day of DQ report monthDefine the managed care plan population from segment MANAGED-CARE-MAIN-MCR00002 by keeping active records that satisfy the following criteria:1. MANAGED-CARE-MAIN-REC-EFF-DATE <= last day of the reporting month2. MANAGED-CARE-MAIN-REC-END-DATE >= last day of the reporting month OR missingSTEP 4: Active non-duplicate paid LT claims during 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 5: Medicaid and S-CHIP Capitation Payment and Encounter: Paid ClaimsOf the claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-CLAIM = (“2” or "3" or “B” or "C")STEP 6: Define Plan_IdDefine Plan_Id as a unique list of: MANAGED-CARE-PLAN-ID from the EL file that meet the constraints in STEP 2, STATE-PLAN-ID-NUM from the MCR file that meet the constraints in STEP 3, and PLAN-ID-NUMBER from the claims files that meet the constraints in STEP 5. Also, define a blank Plan_Id for missing.STEP 7: Medicaid and S-CHIP Encounter: Original, Paid ClaimsOf the claims that meet the criteria from STEP 6, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "3" or "C"2. ADJUSTMENT-IND = "0" STEP 8: Exclude sub-capitation encountersOf the claims that meet the criteria from STEP 7, further restrict them by the following criteria:1. SOURCE-LOCATION is NOT equal to "22" or "23"STEP 9: Exclude childless headersOf the claim headers that meet the criteria from STEP 8, drop all headers that do not merge to at least one lineSTEP 10: Claims paid at the line levelOf claims that meet the criteria from STEP 9, further restrict them by the following criteria:1. PAYMENT-LEVEL-IND = "2"STEP 11: Sum Medicaid paid amount from the claim linesOf the claim lines that meet the criteria from STEP 8, sum the MEDICAID-PAID-AMT values to the header level**Note: Missing values are converted to 0 before calculating the sumSTEP 12: Sum does not match total Medicaid paid amountKeep the claims where the sum from STEP 11 does NOT equal the TOT-MEDICAID-PAID-AMT from the header record**Note: Missing values are converted to 0 before comparisonSTEP 13: Calculate the percentage for the measureDivide the count of claims from STEP 12 by the count of claims from STEP 11STEP 14: Repeat for each Plan_IdREPEAT STEPS 7-13 for each Plan_Id identified in STEP 6 |
STEP 1: Enrolled on the last day of DQ report monthDefine 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 missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Managed care enrollment on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 1, 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 month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 3: Managed care plans on the last day of DQ report monthDefine the managed care plan population from segment MANAGED-CARE-MAIN-MCR00002 by keeping active records that satisfy the following criteria:1. MANAGED-CARE-MAIN-REC-EFF-DATE <= last day of the reporting month2. MANAGED-CARE-MAIN-REC-END-DATE >= last day of the reporting month OR missingSTEP 4: Active non-duplicate paid LT claims during 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 5: Medicaid and S-CHIP Capitation Payment and Encounter: Paid ClaimsOf the claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. TYPE-OF-CLAIM = (“2” or "3" or “B” or "C")STEP 6: Define Plan_IdDefine Plan_Id as a unique list of: MANAGED-CARE-PLAN-ID from the EL file that meet the constraints in STEP 2, STATE-PLAN-ID-NUM from the MCR file that meet the constraints in STEP 3, and PLAN-ID-NUMBER from the claims files that meet the constraints in STEP 5. Also, define a blank Plan_Id for missing.STEP 7: Medicaid and S-CHIP Encounter: Original, Paid ClaimsOf the claims that meet the criteria from STEP 5, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "3" or "C"2. ADJUSTMENT-IND = "0" STEP 8: Exclude sub-capitation encountersOf the claims that meet the criteria from STEP 7, further restrict them by the following criteria:1. SOURCE-LOCATION is NOT equal to "22" or "23"STEP 9: Exclude childless headersOf the claim headers that meet the criteria from STEP 8, drop all headers that do not merge to at least one lineSTEP 10: Claims paid at the line levelOf claims that meet the criteria from STEP 9, further restrict them by the following criteria:1. PAYMENT-LEVEL-IND = "2"STEP 11: Sum Medicaid paid amount from the claim linesOf the claim lines that meet the criteria from STEP 10, sum the MEDICAID-PAID-AMT values to the header level**Note: Missing values are converted to 0 before calculating the sumSTEP 12: Sum does not match total Medicaid paid amountKeep the claims where the sum from STEP 11 does NOT equal the TOT-MEDICAID-PAID-AMT from the header record**Note: Missing values are converted to 0 before comparisonSTEP 13: Calculate the percentage for the measureDivide the count of claims from STEP 12 by the count of claims from STEP 11STEP 14: Repeat for each Plan_IdREPEAT STEPS 7-13 for each Plan_Id identified in STEP 6 |