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TMSIS Dataguide Medicaid.gov

Version:

3.38.0

MCR-65-005-5

Data Quality Measure
Last updated

Key Information

Measure Name % of Pharmacy PAHP (MANAGED-CARE-PLAN-TYPE = 18) enrollees with no capitation payments for Pharmacy PAHPs
File Type Multiple Files
Measure ID MCR-65-005-5
Measure Type Non-Claims Percentage
Content area ELG MCR MULTI

Validation

Validation Type Inferential

Measure Priority

Measure Priority High
Focus Area Managed care
Category Program participation

Claim Information

Claim Type N/A
Adjustment Type N/A
Crossover Type N/A

Thresholds

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

Data Elements

DD Data Element MANAGED-CARE-PLAN-TYPE • MSIS-IDENTIFICATION-NUM • MSIS-IDENTIFICATION-NUM • MSIS-IDENTIFICATION-NUM • MSIS-IDENTIFICATION-NUM • PAYEE-ID • PAYEE-ID • MANAGED-CARE-PLAN-ID • PAYEE-ID
DD Data Element Number ELG193 • FTX042 • ELG191 • FTX173 • FTX086 • FTX078 • FTX033 • ELG192 • FTX163

Annotation Calculate the percentage of eligibles enrolled in a Pharmacy PAHP that do not have Medicaid Capitation Payment Financial Transaction records
Specification STEP 1: 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 2: Managed care participation on the last day of DQ report month

Of 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 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 3: Enrollment in Pharmacy PAHP

Of the MSIS IDs that meet the criteria for STEP 2, further refine the population to MSIS IDs where MANAGED-CARE-PLAN-TYPE = ("18")



STEP 4: Active non-duplicate paid capitation payment financial transactions during report month

Define the FTX universe for the FTX0002, FTX0003, and FTX0005 tables respectively 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 5: Medicaid & S-CHIP Capitation Payment

Of the records that meet the criteria from STEP 4, further restrict them by the following criteria:

1. PAYEE-ID-TYPE = "02"



STEP 6: Cost-Sharing Offset Transaction Type

Of the records that meet the criteria from STEP 5, for those in FTX0005 only, further restrict them by the following criteria:

1. OFFSET-TRANS-TYPE is not "03"



STEP 7: Link MSIS IDs from EL to FTX

Retain the MSIS IDs from STEP 3 that link to an FTX record from STEP 6 using the Plan ID (PAYEE-ID in the FTX record)



STEP 8: Count MSIS IDs without Pharmacy PAHP

Subtract the number of unique MSIS IDs in STEP 7 from the number of unique MSIS IDs in STEP 3



STEP 9: Calculate percentage

Divide the count of unique MSIS IDs in STEP 8 by the count of unique MSIS IDs in STEP 3