ALL-12-001-1

Data Quality Measure

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Key Information

Measure Name	% of claim headers with PROGRAM TYPE = 01, 02, or 04 (EPSDT, family planning, or FQHC)
File Type	COT
Measure ID	ALL-12-001-1
Measure Type	Claims Percentage
Content area	ALL

Validation

Validation Type	Inferential

Measure Priority

Measure Priority	Medium
Focus Area	N/A
Category	Utilization

Claim Information

Claim Type	Medicaid,FFS or Medicaid,Enc or CHIP,FFS or CHIP,Enc
Adjustment Type	Original
Crossover Type	Non-Crossover

Thresholds

Minimum	0.01
Maximum	0.15
TA Minimun	0.01
TA Maximum	0.15
Longitudinal Threshold	N/A
For TA (for including in compliance training)	TA- Inferential
For TA (Longitudinal)	No

Data Elements

DD Data Element	PROGRAM-TYPE
DD Data Element Number	COT065

Annotation	Calculate the percentage of Medicaid and S-CHIP FFS and Encounter: original and adjustment, paid OT claims that are classified as EPSDT, family planning, or FQHC according to program type
Specification	STEP 1: Active non-duplicate OT records during DQ report month Define the OT records 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 and S-CHIP FFS and 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 = "1" or "3" or "A" or "C" 2. ADJUSTMENT-IND = "0" 3. CROSSOVER-INDICATOR = "0" or is missing STEP 3: EPSDT, Family planning, FQHC Of the claims that meet the criteria from STEP 2, limit to those that satisfy the following criterion: 1. PROGRAM-TYPE = "01" or "02" or "04" STEP 4: Calculate percentage Divide the count of claims from STEP 3 by the count in STEP 2

Annotation

Calculate the percentage of Medicaid and S-CHIP FFS and Encounter: original and adjustment, paid OT claims that are classified as EPSDT, family planning, or FQHC according to program type

Specification

STEP 1: Active non-duplicate OT records during DQ report month

Define the OT records 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 and S-CHIP FFS and 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 = "1" or "3" or "A" or "C"

2. ADJUSTMENT-IND = "0"

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

STEP 3: EPSDT, Family planning, FQHC

Of the claims that meet the criteria from STEP 2, limit to those that satisfy the following criterion:

1. PROGRAM-TYPE = "01" or "02" or "04"

STEP 4: Calculate percentage

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