MCR-66-001-1

Data Quality Measure

Last updated

Key Information

Measure Name	% of encounters indicating sub-capitated encounter records from sub-capitated entities that are not sub-capitated network providers (SOURCE-LOCATION = 22)
File Type	CIP
Measure ID	MCR-66-001-1
Measure Type	Claims Percentage
Content area	MCR

Validation

Validation Type	Inferential

Measure Priority

Measure Priority	N/A
Focus Area	N/A
Category	N/A

Claim Information

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

Thresholds

Minimum	TBD
Maximum	TBD
TA Minimun
TA Maximum
Longitudinal Threshold	N/A
For TA (for including in compliance training)	No
For TA (Longitudinal)	No

Data Elements

DD Data Element	SOURCE-LOCATION
DD Data Element Number	CIP104

Annotation	Calculate the percentage of Medicaid and S-CHIP Encounter: original, paid IP claims that are sub-capitated encounters that are not from sub-capitated network providers.
Specification	STEP 1: Active non-duplicate IP claims during DQ report month Define the IP claims universe at the header level that satisfy the following criteria: 1. Reporting Period for the filename = DQ report month 2. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing 3. CLAIM-DENIED-INDICATOR is not equal to "0" or is missing 4. TYPE-OF-CLAIM is not equal to "Z" or is missing 5. CLAIM-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing 6. 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: Original, Paid Claims Of 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-INDICATOR = "0" STEP 3: Medicaid and S-CHIP Encounter: Original, Paid Claims Of the claims that meet the criteria from STEP 2, select claims not from sub-capitated network providers: 1. SOURCE-LOCATION = "22" STEP 4 : Calculate the percentage for the measure Divide the count of claims from STEP 3 by the count of claims from STEP 2

Annotation

Calculate the percentage of Medicaid and S-CHIP Encounter: original, paid IP claims that are sub-capitated encounters that are not from sub-capitated network providers.

Specification

STEP 1: Active non-duplicate IP claims during DQ report month

Define the IP claims universe at the header level that satisfy the following criteria:

1. Reporting Period for the filename = DQ report month

2. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing

3. CLAIM-DENIED-INDICATOR is not equal to "0" or is missing

4. TYPE-OF-CLAIM is not equal to "Z" or is missing

5. CLAIM-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing

6. 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: Original, Paid Claims

Of 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-INDICATOR = "0"

STEP 3: Medicaid and S-CHIP Encounter: Original, Paid Claims

Of the claims that meet the criteria from STEP 2, select claims not from sub-capitated network providers:

1. SOURCE-LOCATION = "22"

STEP 4 : Calculate the percentage for the measure

Divide the count of claims from STEP 3 by the count of claims from STEP 2