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Measure Name | % of MSIS IDs on crossover claim headers not enrolled as duals (QMB, QMB Plus, SLMB Plus, Other) on Beginning Date of Service |
---|---|
File Type | Multiple Files |
Measure ID | ALL-14-003-3 |
Measure Type | Claims Percentage |
Content area | ALL |
Validation Type | Inferential |
---|
Measure Priority | High |
---|---|
Focus Area | N/A |
Category | Beneficiary eligibility |
Claim Type | Medicaid,FFS or Medicaid,Enc |
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Adjustment Type | All Adjustment Types |
Crossover Type | Crossover |
Minimum | 0 |
---|---|
Maximum | 0.05 |
TA Minimun | 0 |
TA Maximum | 0.05 |
Longitudinal Threshold | N/A |
For TA
(for including in compliance training) |
TA- Inferential |
For TA
(Longitudinal) |
No |
DD Data Element | MSIS-IDENTIFICATION-NUM • MSIS-IDENTIFICATION-NUM • DUAL-ELIGIBLE-CODE • BEGINNING-DATE-OF-SERVICE • ELIGIBILITY-DETERMINANT-EFF-DATE • ELIGIBILITY-DETERMINANT-END-DATE |
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DD Data Element Number | COT022 • ELG251 • ELG085 • COT033 • ELG099 • ELG100 |
Annotation | Calculate the percentage of MSIS IDs on Medicaid FFS and Encounter: original and adjustment, crossover 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 service date on the claims file, and 3) are not enrolled as duals |
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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 and Adjustment, 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" 2. CROSSOVER-IND = "1" STEP 3: Non-missing beginning service date 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 ENROLLEMENT-TIME-SPAN-ELG00021 segment STEP 5: Eligible during service date 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. DUAL-ELIGIBLE-CODE not equal to (“01” or “02” or “04” or “08”) or is missing 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: Calculate percentage Divide the count of MSIS-IDs from STEP 6 by the count of MSIS-IDs in STEP 3 |