MCR-S-012-2

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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 Type	Longitudinal and Inferential

Measure Priority	Medium
Focus Area	Managed care
Category	Expenditures

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

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

DD Data Element
DD Data Element Number

Annotation	N/A
Specification	N/A

Published Date	Data Guide Version	DQM	Action	Field	Before	After
11/20/2025	4.0.22	MCR-S-012-2	UPDATE	Annotation	Percentage of Medicaid Encounter: original and adjustment, paid IP claims that are original	N/A
11/20/2025	4.0.22	MCR-S-012-2	UPDATE	Specification	STEP 1: Active non-duplicate IP claims during DQ report monthDefine the IP claims universe at the header level that satisfy the following criteria:1. Reporting Period from the filename = DQ report month2. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing3. CLAIM-DENIED-CATEGORY is not equal to "0" or is missing4. TYPE-OF-CLAIM is not equal to "Z" or is missing5. CLAIM-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing6. 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 ClaimsOf 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 claimsOf the claims that meet the criteria in STEP 2, select records where:1. ADJUSTMENT_IND = "0"STEP 4: Calculate the percentage for the measureDivide the count of claims from STEP 3 by the count of claims from STEP 2.	N/A
04/24/2025	4.0.7	MCR-S-012-2	ADD	N/A		Created

MCR-S-012-2

Key Information

Validation

Measure Priority

Claim Information

Thresholds

Data Elements