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TMSIS Dataguide Medicaid.gov
Version 3.27.0

ALL-16-011-11

Data Quality Measure
Last updated

Key Information

Measure Name % of claim lines with TYPE-OF-SERVICE= “025” or “085” (OT) linked to an MSIS ID where SEX = “M”
File Type Multiple Files
Measure ID ALL-16-011-11
Measure Type Claims Percentage
Content area ELG ALL MULTI

Validation

Validation Type Inferential

Measure Priority

Measure Priority N/A
Focus Area N/A
Category N/A

Claim Information

Claim Type Medicaid,FFS or Medicaid,Cap or Medicaid,Enc or Medicaid,Serv or Medicaid,Supp or CHIP,FFS or CHIP,Cap or CHIP,Enc or CHIP,Serv or CHIP,Supp
Adjustment Type All Adjustment Types
Crossover Type All Indicators

Thresholds

Minimum TBD
Maximum TBD
TA Minimun
TA Maximum
Longitudinal Threshold N/A
For TA
(for including in compliance training) 		No
For TA
(Longitudinal) 		No

Data Elements

DD Data Element MSIS-IDENTIFICATION-NUM • SEX • MSIS-IDENTIFICATION-NUM • TYPE-OF-SERVICE
DD Data Element Number ELG019 • ELG023 • COT157 • COT186

Annotation Calculate the percentage of OT claim lines with TYPE-OF-SERVICE= "025" or "085” that are linked to an MSIS ID where SEX is "M"
Specification STEP 1: Active non-duplicate OT records during DQ report month

Define the OT records universe at the line level by importing 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-ADJSTMT-IND.



STEP 2: Non-missing beginning date of service

Of the claim lines that meet the criteria from STEP 1, restrict to non-missing BEGINNING-DATE-OF-SERVICE



STEP 3: Link claims to primary demographics

Keep all claims from STEP 2 for which the MSIS ID on the claim is also found on a PRIMARY-DEMOGRAPHICS-ELG00002 segment, where the following is true:

1. Claims BEGINNING-DATE-OF-SERVICE>= PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE

2. Claims BEGINNING-DATE-OF-SERVICE <= PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE OR missing



STEP 4: Non-missing Sex

Of the claims that meet the criteria from STEP 3, restrict to non-missing SEX



STEP 5: Nurse-midwife service or Prenatal care and pre-pregnancy family planning services and supplies type of service

Of claims that meet the criteria from STEP 4, further restrict them by the following criteria:

1. TYPE-OF-SERVICE = "025" or "085"



STEP 6: Sex is "M"

Of claims that meet the criteria from STEP 5, further restrict them by the following criteria:

1. SEX = "M"



STEP 7: Calculate percentage

Divide the count of claim lines from STEP 6 by the count of claim lines from STEP 5