PRV-6-001-1

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TMSIS Dataguide

Medicaid.gov

Version:

PRV-6-001-1

Data Quality Measure

Last updated

Key Information

Measure Name	% of Submitting State Provider IDs with FACILITY-GROUP-INDIVIDUAL-CODE = 01, 02 (facility or group) that do not have a Provider Classification Code that indicates a facility or group
File Type	PRV
Measure ID	PRV-6-001-1
Measure Type	Non-claims percentage
Content area	PRO

Validation

Validation Type	Inferential

Measure Priority

Measure Priority	Medium
Focus Area	N/A
Category	Provider identifiers

Claim Information

Claim Type	N/A
Adjustment Type	N/A
Crossover Type	N/A

Thresholds

Minimum	0
Maximum	0.2
TA Minimun	0
TA Maximum	0.2
Longitudinal Threshold	N/A
For TA (for including in compliance training)	TA- Inferential
For TA (Longitudinal)	No

Data Elements

DD Data Element	FACILITY-GROUP-INDIVIDUAL-CODE • SUBMITTING-STATE-PROV-ID • PROV-CLASSIFICATION-CODE • PROV-CLASSIFICATION-TYPE
DD Data Element Number	PRV026 • PRV019 • PRV089 • PRV088

Annotation	N/A
Specification	N/A

Published Date	Data Guide Version	DQM	Action	Field	Before	After
11/20/2025	4.0.22	PRV-6-001-1	UPDATE	Annotation	Calculate the percentage of submitting state provider IDs that have a facility group individual code indicating facility or group but whose provider classification code does not indicate facility or group	N/A
11/20/2025	4.0.22	PRV-6-001-1	UPDATE	Specification	STEP 1: Provider enrolled on the last day of DQ report monthDefine the provider population from segment PROV-MEDICAID-ENROLLMENT-PRV00007 by keeping active records that satisfy the following criteria:1. PROV-MEDICAID-EFF-DATE <= last day of the reporting month2. PROV-MEDICAID-END-DATE >= last day of the reporting month OR missing3. SUBMITTING-STATE-PROV-ID is not missingSTEP 2: Provider attributes are active on last day of DQ report monthOf the providers that meet the criteria from STEP 1, further refine the population using segment PROVIDER-ATTRIBUTES-MAIN- PRV00002 by keeping records that satisfy the following criteria:1. PROV-ATTRIBUTES-EFF-DATE <= last day of the reporting month2. PROV-ATTRIBUTES-END-DATE >= last day of the reporting month or missing3. SUBMITTING-STATE-PROV-ID is not missingSTEP 3: Provider is a facility or groupOf the SUBMITTING-STATE-PROV-IDs that meet the criteria from STEP 2, further refine the population by keeping records that satisfy the following criteria:1. FACILITY-GROUP-INDIVIDUAL-CODE = "01" or "02" STEP 4: Provider taxonomy is active on the last day of DQ report monthOf the providers that meet the criteria from STEP 3, further refine the population using segment PROVIDER-TAXONOMY-CLASSIFICATION-PRV00006 by keeping records that satisfy the following criteria:1a. PROV-TAXONOMY-CLASSIFICATION-EFF-DATE <= last day of the reporting month2a. PROV-TAXONOMY-CLASSIFICATION-END-DATE >= last day of the reporting month OR missingOR1b. PROV-TAXONOMY-CLASSIFICATION-EFF-DATE is missing2b. PROV-TAXONOMY-CLASSIFICATION-END-DATE is missingSTEP 5: Provider Classification Lookup Designation is "Individual" or missingOf the SUBMITTING-STATE-PROV-IDs that meet the criteria from STEP 4, further refine the population by keeping records that meet the following criteria:1a. PROV-IDENTIFIER-TYPE and PROVIDER-CLASSIFICATION-CODE match values in Provider Classification lookup tableAND1b. Provider Classification Lookup Designation is never “Non-Individual”OR2. PROV-IDENTIFIER-TYPE and PROVIDER-CLASSIFICATION-CODE are never equal to values in Provider Classification lookup tableOR3. PROV-IDENTIFIER-TYPE is always missingOR4. PROVIDER-CLASSIFICATION-CODE is always missingSTEP 6: Calculate percentageDivide the count of unique SUBMITTING-STATE-PROVIDER-IDENTIFIER values from STEP 5 by the count of unique SUBMITTING-STATE-PROVIDER-IDENTIFIER values from STEP 3	N/A
04/24/2025	4.0.7	PRV-6-001-1	ADD	N/A		Created