ALL-13-003-5

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TMSIS Dataguide

Medicaid.gov

Version 3.27.0

ALL-13-003-5

Data Quality Measure

Last updated

Key Information

Measure Name	% of MSIS IDs with alien restricted benefits code status (RESTRICTED-BENEFITS-CODE = 2) with services that are not emergency room or pregnancy-related
File Type	Multiple Files
Measure ID	ALL-13-003-5
Measure Type	Claims Percentage
Content area	ALL

Validation

Validation Type	Inferential

Measure Priority

Measure Priority	Medium
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	0.15
TA Minimun	0
TA Maximum	0.15
Longitudinal Threshold	N/A
For TA (for including in compliance training)	TA- Inferential
For TA (Longitudinal)	No

Data Elements

DD Data Element	MSIS-IDENTIFICATION-NUM • ADMISSION-DATE • MSIS-IDENTIFICATION-NUM • RESTRICTED-BENEFITS-CODE • ELIGIBILITY-DETERMINANT-EFF-DATE • ELIGIBILITY-DETERMINANT-END-DATE • REVENUE-CODE • DIAGNOSIS-CODE-1 • DIAGNOSIS-CODE-2 • DIAGNOSIS-CODE-12 • PROCEDURE-CODE-1 • PROCEDURE-CODE-2 • PROCEDURE-CODE-6
DD Data Element Number	CIP022 • CIP094 • ELG251 • ELG097 • ELG099 • ELG100 • CIP245 • CIP032 • CIP035 • CIP065 • CIP070 • CIP074 • CIP090

Annotation

The percentage of MSIS IDs with a restricted benefits code of 2 (alien status) that have Medicaid FFS and Encounter: original, paid IP claims that are not emergency room or pregnancy-related services

Specification

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

Define the IP records universe at the header level by importing both headers and lines that satisfy the following criteria:

For Headers:

1. Reporting Period from 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.

For Lines:

1. Reporting Period from the filename = DQ report month

2. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing

3. No Line Duplicates: Duplicates are dropped at the line level if the following data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, LINE-NUM-ORIG, LINE-NUM-ADJ, and LINE-ADJSTMT-IND.

4. Lines merge to a header using ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND=LINE-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 admission date

Of the claims that meet the criteria from STEP 2, restrict to non-missing ADMISSION-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: Alien 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 = "2"

3. Claims ADMISSION-DATE>= ELIGIBILITY-DETERMINANT-EFF-DATE

4. Claims ADMISSION-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-emergency room and non-pregnancy related services

Of the claims that meet the criteria from STEP 5, restrict to claims with that do NOT have emergency room revenue codes or pregnancy-related diagnosis codes or procedure codes:

NOT

(1a. REVENUE-CODE equal to ("450", "451", "452", "453", "454", "455", "456", "457", "458", "459", "0450", "0451", "0452", "0453", "0454", "0455", "0456", "0457", "0458", "0459" ,“0981”,“0720”, “0721”, “0722”, “0723”, “0724”, “0729”)

OR

2a. DIAGNOSIS-CODE-1 through DIAGNOSIS-CODE-12 is found in the Pregnancy CodeSet tab for ICD-10-CM code types

OR

3a. PROCEDURE-CODE-1 through PROCEDURE-CODE-6 is found in the Pregnancy CodeSet tab for ICD-10-PCM code types)

STEP 8: Calculate percentage

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

Published Date	Data Guide Version	DQM	Action	Field	Before	After
11/15/2023	3.16.0	ALL-13-003-5	UPDATE	Specification	STEP 1: Active non-duplicate IP records during DQ report monthDefine the IP records universe at the header level that satisfy the following criteria:1. Reporting Period for the filename = DQ report month2. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing3. CLAIM-DENIED-INDICATOR is not equal to "0" or is missing4. TYPE-OF-CLAIM is not equal to "Z" or is missing5. CLAIM-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing6. 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 ClaimsOf 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 admission dateOf the claims that meet the criteria from STEP 2, restrict to non-missing ADMISSION-DATESTEP 4: Link claims to enrollment time spanKeep all claims from STEP 3 for which the MSIS ID on the claim is also found on an ENROLLMENT-TIME-SPAN-ELG00021 segmentSTEP 5: Alien during date of serviceLink 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 = 12. RESTRICTED-BENEFIT-CODE = "2"3. Claims ADMISSION-DATE>= ELIGIBILITY-DETERMINANT-EFF-DATE4. Claims ADMISSION-DATE <= ELIGIBILITY-DETERMINANT-END-DATE OR ELIGIBILITY-DETERMINANT-END-DATE is missingSTEP 6: Unique MSIS-IDs in claimsOf the claims that meet the criteria from STEP 5, limit to unique MSIS-IDsSTEP 7: Non-emergency room and non-pregnancy related servicesOf the claims that meet the criteria from STEP 5, restrict to claims with that do NOT have emergency room revenue codes or pregnancy-related diagnosis codes or procedure codes:NOT (1a. REVENUE-CODE equal to ("450", "451", "452", "453", "454", "455", "456", "457", "458", "459", "0450", "0451", "0452", "0453", "0454", "0455", "0456", "0457", "0458", "0459" ,“0981”,“0720”, “0721”, “0722”, “0723”, “0724”, “0729”)OR2a. DIAGNOSIS-CODE-1 through DIAGNOSIS-CODE-12 is found in the Pregnancy CodeSet tab for ICD-10-CM code typesOR3a. PROCEDURE-CODE-1 through PROCEDURE-CODE-6 is found in the Pregnancy CodeSet tab for ICD-10-PCM code types)STEP 8: Calculate percentageDivide the count of unique MSIS-IDs from STEP 7 by the count of MSIS-IDs from STEP 6	STEP 1: Active non-duplicate IP records during DQ report monthDefine the IP records universe at the header level by importing both headers and lines that satisfy the following criteria:For Headers:1. Reporting Period from the filename = DQ report month2. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing3. CLAIM-DENIED-INDICATOR is not equal to "0" or is missing4. TYPE-OF-CLAIM is not equal to "Z" or is missing5. CLAIM-STATUS is not equal to ("26","026","87","087","542","585", "654") or is missing6. 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.For Lines:1. Reporting Period from the filename = DQ report month2. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing3. No Line Duplicates: Duplicates are dropped at the line level if the following data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, LINE-NUM-ORIG, LINE-NUM-ADJ, and LINE-ADJSTMT-IND.4. Lines merge to a header using ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND=LINE-ADJUSTMENT-IND.STEP 2: Medicaid FFS and Encounter: Original, Paid ClaimsOf 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 admission dateOf the claims that meet the criteria from STEP 2, restrict to non-missing ADMISSION-DATESTEP 4: Link claims to enrollment time spanKeep all claims from STEP 3 for which the MSIS ID on the claim is also found on an ENROLLMENT-TIME-SPAN-ELG00021 segmentSTEP 5: Alien during date of serviceLink 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 = 12. RESTRICTED-BENEFIT-CODE = "2"3. Claims ADMISSION-DATE>= ELIGIBILITY-DETERMINANT-EFF-DATE4. Claims ADMISSION-DATE <= ELIGIBILITY-DETERMINANT-END-DATE OR ELIGIBILITY-DETERMINANT-END-DATE is missingSTEP 6: Unique MSIS-IDs in claimsOf the claims that meet the criteria from STEP 5, limit to unique MSIS-IDsSTEP 7: Non-emergency room and non-pregnancy related servicesOf the claims that meet the criteria from STEP 5, restrict to claims with that do NOT have emergency room revenue codes or pregnancy-related diagnosis codes or procedure codes:NOT (1a. REVENUE-CODE equal to ("450", "451", "452", "453", "454", "455", "456", "457", "458", "459", "0450", "0451", "0452", "0453", "0454", "0455", "0456", "0457", "0458", "0459" ,“0981”,“0720”, “0721”, “0722”, “0723”, “0724”, “0729”)OR2a. DIAGNOSIS-CODE-1 through DIAGNOSIS-CODE-12 is found in the Pregnancy CodeSet tab for ICD-10-CM code typesOR3a. PROCEDURE-CODE-1 through PROCEDURE-CODE-6 is found in the Pregnancy CodeSet tab for ICD-10-PCM code types)STEP 8: Calculate percentageDivide the count of unique MSIS-IDs from STEP 7 by the count of MSIS-IDs from STEP 6
06/02/2023	3.8.0	ALL-13-003-5	UPDATE	Specification	STEP 1: Active non-duplicate IP records during DQ report monthDefine the IP records universe at the header level that satisfy the following criteria:1. Reporting Period for the filename = DQ report month2. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing3. CLAIM-DENIED-INDICATOR is not equal to "0" or is missing4. TYPE-OF-CLAIM is not equal to "Z" or is missing5. CLAIM-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing6. 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 ClaimsOf 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 serviceOf the claims that meet the criteria from STEP 2, restrict to non-missing ADMISSION-DATESTEP 4: Link claims to enrollment time spanKeep all claims from STEP 3 for which the MSIS ID on the claim is also found on an ENROLLMENT-TIME-SPAN-ELG00021 segmentSTEP 5: Alien during date of serviceLink 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 = 12. RESTRICTED-BENEFIT-CODE = "2"3. Claims ADMISSION-DATE>= ELIGIBILITY-DETERMINANT-EFF-DATE4. Claims ADMISSION-DATE <= ELIGIBILITY-DETERMINANT-END-DATE OR ELIGIBILITY-DETERMINANT-END-DATE is missingSTEP 6: Unique MSIS-IDs in claimsOf the claims that meet the criteria from STEP 5, limit to unique MSIS-IDsSTEP 7: Non-emergency room and non-pregnancy related servicesOf the claims that meet the criteria from STEP 5, restrict to claims with that do NOT have emergency room revenue codes or pregnancy-related diagnosis codes or procedure codes:NOT (1a. REVENUE-CODE equal to ("450", "451", "452", "453", "454", "455", "456", "457", "458", "459", "0450", "0451", "0452", "0453", "0454", "0455", "0456", "0457", "0458", "0459" ,“0981”,“0720”, “0721”, “0722”, “0723”, “0724”, “0729”)OR2a. DIAGNOSIS-CODE-1 through DIAGNOSIS-CODE-12 is found in the Pregnancy CodeSet tab for ICD-10-CM code typesOR3a. PROCEDURE-CODE-1 through PROCEDURE-CODE-6 is found in the Pregnancy CodeSet tab for ICD-10-PCM code types)STEP 8: Calculate percentageDivide the count of unique MSIS-IDs from STEP 7 by the count of MSIS-IDs from STEP 6	STEP 1: Active non-duplicate IP records during DQ report monthDefine the IP records universe at the header level that satisfy the following criteria:1. Reporting Period for the filename = DQ report month2. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing3. CLAIM-DENIED-INDICATOR is not equal to "0" or is missing4. TYPE-OF-CLAIM is not equal to "Z" or is missing5. CLAIM-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing6. 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 ClaimsOf 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 admission dateOf the claims that meet the criteria from STEP 2, restrict to non-missing ADMISSION-DATESTEP 4: Link claims to enrollment time spanKeep all claims from STEP 3 for which the MSIS ID on the claim is also found on an ENROLLMENT-TIME-SPAN-ELG00021 segmentSTEP 5: Alien during date of serviceLink 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 = 12. RESTRICTED-BENEFIT-CODE = "2"3. Claims ADMISSION-DATE>= ELIGIBILITY-DETERMINANT-EFF-DATE4. Claims ADMISSION-DATE <= ELIGIBILITY-DETERMINANT-END-DATE OR ELIGIBILITY-DETERMINANT-END-DATE is missingSTEP 6: Unique MSIS-IDs in claimsOf the claims that meet the criteria from STEP 5, limit to unique MSIS-IDsSTEP 7: Non-emergency room and non-pregnancy related servicesOf the claims that meet the criteria from STEP 5, restrict to claims with that do NOT have emergency room revenue codes or pregnancy-related diagnosis codes or procedure codes:NOT (1a. REVENUE-CODE equal to ("450", "451", "452", "453", "454", "455", "456", "457", "458", "459", "0450", "0451", "0452", "0453", "0454", "0455", "0456", "0457", "0458", "0459" ,“0981”,“0720”, “0721”, “0722”, “0723”, “0724”, “0729”)OR2a. DIAGNOSIS-CODE-1 through DIAGNOSIS-CODE-12 is found in the Pregnancy CodeSet tab for ICD-10-CM code typesOR3a. PROCEDURE-CODE-1 through PROCEDURE-CODE-6 is found in the Pregnancy CodeSet tab for ICD-10-PCM code types)STEP 8: Calculate percentageDivide the count of unique MSIS-IDs from STEP 7 by the count of MSIS-IDs from STEP 6
04/21/2023	3.6.0	ALL-13-003-5	UPDATE	Measure name	% alien restricted benefits code status (RESTRICTED-BENEFITS-CODE = 2) with services that are not emergency room or pregnancy-related	% of MSIS IDs with alien restricted benefits code status (RESTRICTED-BENEFITS-CODE = 2) with services that are not emergency room or pregnancy-related