MCR-64-001

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Measure Name	% of crossover claim headers where MEDICARE-PAID-AMT, TOT-MEDICARE-COINS-AMT, and TOT-MEDICARE-DEDUCTIBLE-AMT are 0 or missing
File Type	CIP
Measure ID	MCR-64-001_1-5
Measure Type	Claims Percentage
Content area	MCR

Validation Type	Inferential

Measure Priority	Medium
Focus Area	Managed care
Category	Expenditures

Claim Type	Medicaid,Enc or CHIP,Enc
Adjustment Type	Non-void
Crossover Type	Crossover

Minimum	0
Maximum	0.1
TA Minimun	0
TA Maximum	0.1
Longitudinal Threshold	N/A
For TA (for including in compliance training)	TA- Inferential
For TA (Longitudinal)	No

DD Data Element	TOT-MEDICARE-DEDUCTIBLE-AMT • TOT-MEDICARE-COINS-AMT • MEDICARE-PAID-AMT
DD Data Element Number	CIP116 • CIP117 • CIP228

Annotation	N/A
Specification	N/A

Published Date	Data Guide Version	DQM	Action	Field	Before	After
11/20/2025	4.0.22	MCR-64-001_1-5	UPDATE	Annotation	Calculate the percentage of Medicaid and S-CHIP encounter: non-void, crossover, paid IP claims where Medicare paid amount, total Medicare coinsurance amount, and total Medicare deductible amount are equal to 0 or are missing	N/A
11/20/2025	4.0.22	MCR-64-001_1-5	UPDATE	Specification	STEP 1: Active non-duplicate paid IP claims during report monthDefine the IP claims universe at the header level that satisfy the following criteria: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.STEP 2: Medicaid and S-CHIP Encounter: Non-void, Crossover, 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. CROSSOVER-IND = "1"3. ADJUSTMENT-IND not equal to "1" 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: No Medicare AmountsOf the claims that meet the criteria from STEP 3, further restrict them by the following criteria: 1. MEDICARE-PAID-AMT = 0 or is missing2. TOT-MEDICARE-COINS-AMT = 0 or is missing3. TOT-MEDICARE-DEDUCTIBLE-AMT = 0 or is missingSTEP 5: Calculate percentageDivide the count of claim headers from STEP 4 by the count of claim headers from STEP 3.	N/A
10/07/2025	4.0.19	MCR-64-001_1-5	UPDATE	Grace period expiration date	None	2023-04-30
04/24/2025	4.0.7	MCR-64-001_1-5	ADD	N/A		Created

MCR-64-001_1-5

Key Information

Validation

Measure Priority

Claim Information

Thresholds

Data Elements