ALL-13-001-1

Data Quality Measure

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Key Information

Measure Name	% of MSIS IDs limited to family planning (RESTRICTED-BENEFITS-CODE = 6) with non-family planning services (PROGRAM-TYPE not equal 2)
File Type	Multiple Files
Measure ID	ALL-13-001-1
Measure Type	Claims Percentage
Content area	ALL

Validation

Validation Type	Inferential

Measure Priority

Measure Priority	High
Focus Area	N/A
Category	Beneficiary eligibility

Claim Information

Claim Type	Medicaid,FFS or Medicaid,Enc
Adjustment Type	Original
Crossover Type	All Indicators

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	MSIS-IDENTIFICATION-NUM • BEGINNING-DATE-OF-SERVICE • MSIS-IDENTIFICATION-NUM • RESTRICTED-BENEFITS-CODE • ELIGIBILITY-DETERMINANT-EFF-DATE • ELIGIBILITY-DETERMINANT-END-DATE • PROGRAM-TYPE
DD Data Element Number	COT022 • COT033 • ELG251 • ELG097 • ELG099 • ELG100 • COT065

Annotation	Calculate the percentage of MSIS IDs on Medicaid FFS and Encounter: original, paid OT claims that: 1) can be found on an Eligible file enrollment time span segment, 2) can be found on an Eligible file eligibility determinant segment that spans the beginning date of service on the claims file, and 3) are limited to family planning benefits which also have a non-family planning 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 FFS and Encounter: Original, 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" 2. ADJUSTMENT_IND = "0" STEP 3: Non-missing beginning date of service Of the claims that meet the criteria from STEP 2, restrict to non-missing BEGINNING-DATE-OF-SERVICE STEP 4: Link claims to enrollment time span Keep all claims from STEP 3 for which the MSIS ID on the claim is also found on an ENROLLMENT-TIME-SPAN-ELG00021 segment STEP 5: Family planning during date of service Link MSIS-IDs from the claims in STEP 4 to the ELIGIBILITY-DETERMINANTS-ELG00005 file segment and keep segments that satisfy the following criteria: 1. PRIMARY-ELIGIBILITY-GROUP-IND = 1 2. RESTRICTED-BENEFIT-CODE = "6" 3. Claims BEGINNING-DATE-OF-SERVICE >= ELIGIBILITY-DETERMINANT-EFF-DATE 4. Claims BEGINNING-DATE-OF-SERVICE <= ELIGIBILITY-DETERMINANT-END-DATE OR ELIGIBILITY-DETERMINANT-END-DATE is missing STEP 6: Unique MSIS-IDs in claims Of the claims that meet the criteria from STEP 5, limit to unique MSIS-IDs STEP 7: Non-family planning services Of the claims that meet the criteria from STEP 5, restrict to claims with: 1a. PROGRAM-TYPE not equal to "2" OR 1b. PROGRAM-TYPE is missing STEP 8: Calculate percentage Divide the count of unique MSIS-IDs from STEP 7 by the count of MSIS-IDs from STEP 6

Annotation

Calculate the percentage of MSIS IDs on Medicaid FFS and Encounter: original, paid OT claims that: 1) can be found on an Eligible file enrollment time span segment, 2) can be found on an Eligible file eligibility determinant segment that spans the beginning date of service on the claims file, and 3) are limited to family planning benefits which also have a non-family planning 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 FFS and Encounter: Original, 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"

2. ADJUSTMENT_IND = "0"

STEP 3: Non-missing beginning date of service

Of the claims that meet the criteria from STEP 2, restrict to non-missing BEGINNING-DATE-OF-SERVICE

STEP 4: Link claims to enrollment time span

Keep all claims from STEP 3 for which the MSIS ID on the claim is also found on an ENROLLMENT-TIME-SPAN-ELG00021 segment

STEP 5: Family planning during date of service

Link MSIS-IDs from the claims in STEP 4 to the ELIGIBILITY-DETERMINANTS-ELG00005 file segment and keep segments that satisfy the following criteria:

1. PRIMARY-ELIGIBILITY-GROUP-IND = 1

2. RESTRICTED-BENEFIT-CODE = "6"

3. Claims BEGINNING-DATE-OF-SERVICE >= ELIGIBILITY-DETERMINANT-EFF-DATE

4. Claims BEGINNING-DATE-OF-SERVICE <= ELIGIBILITY-DETERMINANT-END-DATE OR ELIGIBILITY-DETERMINANT-END-DATE is missing

STEP 6: Unique MSIS-IDs in claims

Of the claims that meet the criteria from STEP 5, limit to unique MSIS-IDs

STEP 7: Non-family planning services

Of the claims that meet the criteria from STEP 5, restrict to claims with:

1a. PROGRAM-TYPE not equal to "2"

OR

1b. PROGRAM-TYPE is missing

STEP 8: Calculate percentage

Divide the count of unique MSIS-IDs from STEP 7 by the count of MSIS-IDs from STEP 6