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Measure Name | % of claim lines that have no corresponding claim header |
---|---|
File Type | CRX |
Measure ID | ALL-17-008-8 |
Measure Type | Claims Percentage |
Content area | ALL |
Validation Type | Inferential |
---|
Measure Priority | N/A |
---|---|
Focus Area | N/A |
Category | N/A |
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 |
Minimum | 0 |
---|---|
Maximum | 0.001 |
TA Minimun | |
TA Maximum | |
Longitudinal Threshold | N/A |
For TA
(for including in compliance training) |
No |
For TA
(Longitudinal) |
No |
DD Data Element | |
---|---|
DD Data Element Number |
Annotation | Calculate the percentage of paid RX claim lines that do not link to a claim header |
---|---|
Specification |
STEP 1: Active paid RX claims during DQ report month Define the RX claims universe at the line level by importing both headers and lines that satisfy the following criteria: 1a. Limit to Report Month Reporting Period from the filename = DQ report month 1b. Join Headers and Lines Merge headers and lines using: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND=LINE-ADJSTMT-IND, and keep all claims, including orphan lines 1c. Keep headers and associated lines if header is not denied; keep lines if header is missing (If header is denied also drop associated lines) 1. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing 2. CLAIM-DENIED-INDICATOR is not equal to "0" or is missing 3. TYPE-OF-CLAIM is not equal to "Z" or is missing 4. CLAIM-STATUS is not equal to ("26","026","87","087","542","585", "654") or is missing 1d. Drop line duplicates Duplicates are dropped at the line level, if the following four data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and LINE-ADJUSTMENT-IND. 1e. Keep line if line is not denied 1. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing STEP 2: Orphan lines Of the claim lines that meet the criteria from STEP 1, keep claim lines that did not merge to any claim header STEP 3: Calculate percentage Divide the count of claim lines from STEP 2 by the count of claim lines from STEP 1 |