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Measure Name | % of MSIS IDs limited to family planning (RESTRICTED-BENEFITS-CODE = 6) with non-family planning services (PROGRAM-TYPE not equal 2) |
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File Type | Multiple Files |
Measure ID | ALL-13-002-2 |
Measure Type | Claims Percentage |
Content area | ALL |
Validation Type | Inferential |
---|
Measure Priority | High |
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Focus Area | N/A |
Category | Beneficiary eligibility |
Claim Type | Medicaid,FFS or Medicaid,Enc |
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Adjustment Type | Original |
Crossover Type | All Indicators |
Minimum | 0 |
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Maximum | 0.15 |
TA Minimun | 0 |
TA Maximum | 0.15 |
Longitudinal Threshold | N/A |
For TA
(for including in compliance training) |
TA- Inferential |
For TA
(Longitudinal) |
No |
DD Data Element | MSIS-IDENTIFICATION-NUM • PRESCRIPTION-FILL-DATE • MSIS-IDENTIFICATION-NUM • RESTRICTED-BENEFITS-CODE • ELIGIBILITY-DETERMINANT-EFF-DATE • ELIGIBILITY-DETERMINANT-END-DATE • PROGRAM-TYPE |
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DD Data Element Number | CRX022 • CRX085 • ELG251 • ELG097 • ELG099 • ELG100 • CRX055 |
Annotation | Calculate the percentage of MSIS IDs on Medicaid FFS and Encounter: original, paid RX 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 |
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Specification |
STEP 1: Active non-duplicate RX records during DQ report month Define the RX 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 prescription fill date Of the claims that meet the criteria from STEP 2, restrict to non-missing PRESCRIPTION-FILL-DATE 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 PRESCRIPTION-FILL-DATE >= ELIGIBILITY-DETERMINANT-EFF-DATE 4. Claims PRESCRIPTION-FILL-DATE <= 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 |