Key Information

Measure Name	% of MSIS IDs on crossover claim headers enrolled as premium only dual groups (SLMB, QI, QDWI) on Beginning Date of Service
File Type	Multiple Files
Measure ID	ALL-14-006-6
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	All Adjustment Types
Crossover Type	Crossover

Thresholds

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

Data Elements

DD Data Element	MSIS-IDENTIFICATION-NUM • MSIS-IDENTIFICATION-NUM • DUAL-ELIGIBLE-CODE • BEGINNING-DATE-OF-SERVICE • ELIGIBILITY-DETERMINANT-EFF-DATE • ELIGIBILITY-DETERMINANT-END-DATE
DD Data Element Number	CLT022 • ELG251 • ELG085 • CLT048 • ELG099 • ELG100

Annotation

Calculate the percentage of MSIS IDs on Medicaid FFS and Encounter: original and adjustment, crossover paid LT 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 enrolled as premium only dual

Specification

STEP 1: Active non-duplicate LT records during DQ report month Define the LT 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 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: Not enrolled as duals 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 = (“03” or “05” or “06”) 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