| 11/20/2025 |
4.0.22 |
MCR-65-009-9 |
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 participation 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: Enrollment in Disease ManagementOf the MSIS IDs that meet the criteria for STEP 2, further refine the population to MSIS IDs where MANAGED-CARE-PLAN-TYPE = ("02", "03", or "16")STEP 4: Active non-duplicate paid capitation payment financial transactions during report monthDefine 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 month2. 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 PaymentOf the records that meet the criteria from STEP 4, further restrict them by the following criteria:1. PAYEE-ID-TYPE = "02" or "05" or "06"STEP 6: Cost-Sharing Offset Transaction TypeOf 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 FTXRetain 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 Disease ManagementSubtract the number of unique MSIS IDs in STEP 7 from the number of unique MSIS IDs in STEP 3STEP 9: Calculate percentageDivide the count of unique MSIS IDs in STEP 8 by the count of unique MSIS IDs in STEP 3 |
N/A |
| 10/07/2025 |
4.0.19 |
MCR-65-009-9 |
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 participation 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: Enrollment in Disease ManagementOf the MSIS IDs that meet the criteria for STEP 2, further refine the population to MSIS IDs where MANAGED-CARE-PLAN-TYPE = ("02", "03", or "16")STEP 4: Active non-duplicate paid capitation payment financial transactions during report monthDefine 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 month2. 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 PaymentOf 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 TypeOf 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 FTXRetain 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 Disease ManagementSubtract the number of unique MSIS IDs in STEP 7 from the number of unique MSIS IDs in STEP 3STEP 9: Calculate percentageDivide the count of unique MSIS IDs in STEP 8 by the count of unique MSIS IDs in STEP 3 |
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 participation 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: Enrollment in Disease ManagementOf the MSIS IDs that meet the criteria for STEP 2, further refine the population to MSIS IDs where MANAGED-CARE-PLAN-TYPE = ("02", "03", or "16")STEP 4: Active non-duplicate paid capitation payment financial transactions during report monthDefine 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 month2. 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 PaymentOf the records that meet the criteria from STEP 4, further restrict them by the following criteria:1. PAYEE-ID-TYPE = "02" or "05" or "06"STEP 6: Cost-Sharing Offset Transaction TypeOf 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 FTXRetain 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 Disease ManagementSubtract the number of unique MSIS IDs in STEP 7 from the number of unique MSIS IDs in STEP 3STEP 9: Calculate percentageDivide the count of unique MSIS IDs in STEP 8 by the count of unique MSIS IDs in STEP 3 |
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