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TMSIS Dataguide Medicaid.gov

Version:

3.39.0

TPL-3-004-7

Data Quality Measure
Last updated

Key Information

Measure Name % of claim headers with OTHER-INSURANCE-IND = 1
File Type CRX
Measure ID TPL-3-004-7
Measure Type Claims Percentage
Content area TPL TPL

Validation

Validation Type Longitudinal and Inferential

Measure Priority

Measure Priority Medium
Focus Area N/A
Category Expenditures

Claim Information

Claim Type Medicaid,Enc
Adjustment Type Original
Crossover Type Non-Crossover

Thresholds

Minimum 0.0001
Maximum 0.05
TA Minimun 0.0001
TA Maximum 0.1
Longitudinal Threshold 0.15
For TA
(for including in compliance training) 		TA- Inferential
For TA
(Longitudinal) 		No

Data Elements

DD Data Element OTHER-INSURANCE-IND
DD Data Element Number CRX048

Annotation Calculate the percentage of Medicaid Encounter: original, non-crossover, paid RX claims with other insurance
Specification STEP 1: Active non-duplicate RX claims during DQ report month

Define the RX 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 Encounter: Original, Non-Crossover, Paid Claims

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

1. TYPE-OF-CLAIM = "3"

2. ADJUSTMENT-IND = "0"

3. CROSSOVER-INDICATOR = "0" or is missing



STEP 3: Other insurance

Of the claims that meet the criteria from STEP 2, select claims with other insurance:

1. OTHER-INSURANCE-IND = "1"



STEP 4 : Calculate percentage for measure

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