MCR-9-006_1-18

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TMSIS Dataguide

Medicaid.gov

Version:

MCR-9-006_1-18

Data Quality Measure

Last updated

Key Information

Measure Name	% of PCCM capitation payment records with a non-missing plan ID that do not have a corresponding managed care participation PCCM plan
File Type	Multiple Files
Measure ID	MCR-9-006_1-18
Measure Type	Non-Claims Percentage
Content area	MCR

Validation

Validation Type	Inferential

Measure Priority

Measure Priority	Medium
Focus Area	Managed care
Category	Expenditures

Claim Information

Claim Type	N/A
Adjustment Type	Original
Crossover Type	All Indicators

Thresholds

Minimum	0
Maximum	0.05
TA Minimun	0
TA Maximum	0.05
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 • PAYEE-MCR-PLAN-TYPE • PAYEE-ID • MANAGED-CARE-PLAN-ID • PAYEE-ID-TYPE
DD Data Element Number	ELG193 • FTX042 • ELG191 • FTX036 • FTX033 • ELG192 • FTX034

Annotation

Calculate the percentage of PCCM capitation payment Financial Transaction records with a non-missing plan ID that do not have a corresponding managed care participation PCCM plan

Specification

STEP 1: Active non-duplicate paid individual capitation payment financial transactions during report month

Define the FTX universe for the FTX0002 table 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 2: Managed Care Plan Payee ID Type

Of the records that meet the criteria from STEP 1, further restrict them by the following criteria:

1. PAYEE-MCR-PLAN-TYPE - "02" or "03"

2. PAYEE-ID-TYPE = "02"

STEP 3: Non-missing Payee ID

Of the records that meet the criteria from STEP 2, further restrict them by the following criteria:

1. PAYEE-ID is not missing

STEP 4: 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 5: Managed care enrollment on the last day of DQ report month

Of the MSIS-IDs that meet the criteria from STEP 4, 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 6: No managed care participation PCCM plan

Of the records that meet the criteria from STEP 3, further restrict them by attempting to merge them with the data from STEP 5 and keeping those that satisfy the following criteria:

1a. PAYEE-ID = MANAGED-CARE-PLAN-ID

2a. MSIS-IDENTIFICATION-NUM matches

3a. MANAGED-CARE-PLAN-TYPE does NOT equal "02" or "03" for any records where 1a and 2a are satisfied

OR

It is not the case that:

1b. PAYEE-ID = MANAGED-CARE-PLAN-ID

2b. MSIS-IDENTIFICATION-NUM matches

STEP 7: Calculate the percentage for the measure

Divide the count of records from STEP 6 by the count of records from STEP 3

Published Date	Data Guide Version	DQM	Action	Field	Before	After
05/27/2025	4.0.9	MCR-9-006_1-18	UPDATE	Specification	STEP 1: Active non-duplicate paid individual capitation payment financial transactions during report monthDefine the FTX universe for the FTX0002 table 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 2: Managed Care Plan Payee ID TypeOf the records that meet the criteria from STEP 1, further restrict them by the following criteria:1. MCR-PLAN-TYPE - "02" or "03"2. PAYEE-ID-TYPE = "02"STEP 3: Non-missing Payee IDOf the records that meet the criteria from STEP 2, further restrict them by the following criteria: 1. PAYEE-ID is not missingSTEP 4: 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 5: Managed care enrollment on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 4, 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 6: No managed care participation PCCM planOf the records that meet the criteria from STEP 3, further restrict them by attempting to merge them with the data from STEP 5 and keeping those that satisfy the following criteria:1a. PAYEE-ID = MANAGED-CARE-PLAN-ID2a. MSIS-IDENTIFICATION-NUM matches 3a. MANAGED-CARE-PLAN-TYPE does NOT equal "02" or "03" for any records where 1a and 2a are satisfiedORIt is not the case that:1b. PAYEE-ID = MANAGED-CARE-PLAN-ID2b. MSIS-IDENTIFICATION-NUM matches STEP 7: Calculate the percentage for the measureDivide the count of records from STEP 6 by the count of records from STEP 3	STEP 1: Active non-duplicate paid individual capitation payment financial transactions during report monthDefine the FTX universe for the FTX0002 table 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 2: Managed Care Plan Payee ID TypeOf the records that meet the criteria from STEP 1, further restrict them by the following criteria:1. PAYEE-MCR-PLAN-TYPE - "02" or "03"2. PAYEE-ID-TYPE = "02"STEP 3: Non-missing Payee IDOf the records that meet the criteria from STEP 2, further restrict them by the following criteria: 1. PAYEE-ID is not missingSTEP 4: 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 5: Managed care enrollment on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 4, 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 6: No managed care participation PCCM planOf the records that meet the criteria from STEP 3, further restrict them by attempting to merge them with the data from STEP 5 and keeping those that satisfy the following criteria:1a. PAYEE-ID = MANAGED-CARE-PLAN-ID2a. MSIS-IDENTIFICATION-NUM matches 3a. MANAGED-CARE-PLAN-TYPE does NOT equal "02" or "03" for any records where 1a and 2a are satisfiedORIt is not the case that:1b. PAYEE-ID = MANAGED-CARE-PLAN-ID2b. MSIS-IDENTIFICATION-NUM matches STEP 7: Calculate the percentage for the measureDivide the count of records from STEP 6 by the count of records from STEP 3
04/24/2025	4.0.7	MCR-9-006_1-18	ADD	N/A		Created