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Measure Name | % of active 1915(j) MSIS IDs (STATE-PLAN-OPTION-TYPE = '03') during the reporting period with any claim lines |
---|---|
File Type | Multiple Files |
Measure ID | ALL-2-005-5 |
Measure Type | Claims Percentage |
Content area | ALL |
Validation Type | Longitudinal and Inferential |
---|
Measure Priority | Medium |
---|---|
Focus Area | N/A |
Category | Utilization |
Claim Type | Medicaid,FFS or Medicaid,Enc |
---|---|
Adjustment Type | Original |
Crossover Type | Non-Crossover |
Minimum | 0.8 |
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Maximum | 1 |
TA Minimun | 0.8 |
TA Maximum | 1 |
Longitudinal Threshold | 0.2 |
For TA
(for including in compliance training) |
TA- Inferential |
For TA
(Longitudinal) |
No |
DD Data Element | MSIS-IDENTIFICATION-NUM • STATE-PLAN-OPTION-TYPE • MSIS-IDENTIFICATION-NUM |
---|---|
DD Data Element Number | ELG162 • ELG163 • COT157 |
Annotation | The percentage of active 1915(i) eligibles (STATE-PLAN-OPTION-TYPE = '03') with any Medicaid FFS and Encounter: original, non-crossover, paid OT claims claims during the reporting period |
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Specification |
STEP 1: Enrolled on the last day of DQ report month Define the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria: 1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing 3. MSIS-IDENTIFICATION-NUM is not missing STEP 2: State plan participation on the last day of DQ report month Of the MSIS-IDs that meet the criteria from STEP 1, further refine the population using segment STATE-PLAN-OPTION-PARTICIPATION-ELG00011 by keeping records that satisfy the following criteria: 1a. STATE-PLAN-OPTION-EFF-DATE <= last day of the DQ report month 2a. STATE-PLAN-OPTION-END-DATE >= last day of the DQ report month OR missing OR 1b. STATE-PLAN-OPTION-EFF-DATE is missing 2b. STATE-PLAN-OPTION-END-DATE is missing STEP 3: 1915(j) eligibles Of the MSIS-IDs that meet the criteria from STEP 2, further refine the population by keeping records that satisfy the following criteria: STATE-PLAN-OPTION-TYPE = '03' STEP 4: Active non-duplicate paid OT claims during report month Define the OT claims universe at the line level by importing both headers and 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 5: Medicaid FFS and Encounter: Original, Non-Crossover, Paid Claims Of the claims that meet the criteria from STEP 4, further restrict them by the following criteria: 1. TYPE-OF-CLAIM = "1" or "3" 2. ADJUSTMENT-IND = "0" 3. CROSSOVER-INDICATOR = "0" or is missing STEP 6: Eligibles with OT claims Of the MSIS-IDs from STEP 3, count the number which also appear in the claims from STEP 5 STEP 7: Calculate percentage for measure Divide the number of MSIS-IDs from STEP 6 by the number of MSIS-IDs from STEP 3 |