MCR-S-012-2

Data Quality Measure

Last updated

Key Information

Measure Name	% of claim headers that are original
File Type	CIP
Measure ID	MCR-S-012-2
Measure Type	Claims Percentage
Content area	MCR

Validation

Validation Type	Longitudinal and Inferential

Measure Priority

Measure Priority	Medium
Focus Area	Managed care
Category	Expenditures

Claim Information

Claim Type	Medicaid,Enc
Adjustment Type	All Adjustment Types
Crossover Type	All Indicators

Thresholds

Minimum	0.26
Maximum	0.9999
TA Minimun	0.26
TA Maximum	0.9999
Longitudinal Threshold	0.75
For TA (for including in compliance training)	TA- Inferential
For TA (Longitudinal)	No

Data Elements

DD Data Element
DD Data Element Number

Annotation	Percentage of Medicaid Encounter: original and adjustment, paid IP claims that are original
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 from the filename = DQ report month 2. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing 3. CLAIM-DENIED-CATEGORY 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 Encounter: Original and Adjustment, Paid Claims Of the claims that meet the criteria from STEP 1, further restrict them by the following criteria: 1. TYPE-OF-CLAIM = "3" STEP 3: Medicaid Encounter: Original claims Of the claims that meet the criteria in STEP 2, select records where: 1. ADJUSTMENT_IND = "0" 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

Percentage of Medicaid Encounter: original and adjustment, paid IP claims that are original

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 from the filename = DQ report month

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

3. CLAIM-DENIED-CATEGORY 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 Encounter: Original and Adjustment, Paid Claims

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

1. TYPE-OF-CLAIM = "3"

STEP 3: Medicaid Encounter: Original claims

Of the claims that meet the criteria in STEP 2, select records where:

1. ADJUSTMENT_IND = "0"

STEP 4: Calculate the percentage for the measure

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