ALL-16-015-15

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TMSIS Dataguide

Medicaid.gov

Version 3.27.0

ALL-16-015-15

Data Quality Measure

Last updated

Key Information

Measure Name	% of claim lines with XIX-MBESCBES-CATEGORY-OF-SERVICE = “14”, “35”, “42” or “44” (RX) linked to an MSIS ID where SEX = “M”
File Type	Multiple Files
Measure ID	ALL-16-015-15
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	N/A
Maximum	N/A
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 • XIX-MBESCBES-CATEGORY-OF-SERVICE • SEX • MSIS-IDENTIFICATION-NUM
DD Data Element Number	ELG019 • CRX150 • ELG023 • CRX111

Annotation	N/A
Specification	N/A

Published Date	Data Guide Version	DQM	Action	Field	Before	After
06/19/2024	3.27.0	ALL-16-015-15	UPDATE	Threshold minimum	TBD	N/A
06/19/2024	3.27.0	ALL-16-015-15	UPDATE	Threshold maximum	TBD	N/A
06/19/2024	3.27.0	ALL-16-015-15	UPDATE	Annotation	Calculate the percentage of RX claim lines with XIX-MBESCBES-CATEGORY-OF-SERVICE = “14”, “35”, “42” or “44” that are linked to an MSIS ID where SEX is "M"	N/A
06/19/2024	3.27.0	ALL-16-015-15	UPDATE	Specification	STEP 1: Active non-duplicate RX records during DQ report monthDefine the RX records universe at the line level by importing 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-ADJSTMT-IND.STEP 2: Non-missing prescription fill dateOf the claim lines that meet the criteria from STEP 1, restrict to non-missing PRESCRIPTION-FILL-DATESTEP 3: Link claims to primary demographicsKeep 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 PRESCRIPTION-FILL-DATE>= PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE 2. Claims PRESCRIPTION-FILL-DATE<= PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE OR missingSTEP 4: Non-missing SexOf the claims that meet the criteria from STEP 3, restrict to non-missing SEXSTEP 5: XIX category of serviceOf claims that meet the criteria from STEP 4, further restrict them by the following criteria:1. XIX-MBESCBES-CATEGORY-OF-SERVICE = “14”, “35”, “42” or “44”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 percentageDivide the count of claim lines from STEP 6 by the count of claim lines from STEP 5	N/A
06/02/2023	3.8.0	ALL-16-015-15	ADD	N/A		Created