Key Information

Measure Name	% of 1915(c) waiver enrollees (WAIVER-TYPE = 06 - 20 or 33) that do not have any claim headers with HCBS-SERVICE-CODE = 4
File Type	Multiple Files
Measure ID	ALL-2-011-11
Measure Type	Claims Percentage
Content area	ELG ALL MULTI

Validation

Validation Type	Inferential

Measure Priority

Measure Priority	High
Focus Area	N/A
Category	Program participation

Claim Information

Claim Type	Medicaid,FFS or Medicaid,Enc
Adjustment Type	Original
Crossover Type	All Indicators

Thresholds

Minimum	0
Maximum	0.5
TA Minimun	0
TA Maximum	0.5
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 • WAIVER-TYPE • MSIS-IDENTIFICATION-NUM • HCBS-SERVICE-CODE
DD Data Element Number	ELG171 • ELG173 • COT022 • COT187

Annotation

Calculate the percentage of eligibles enrolled in a 1915(c) waiver that do not have Medicaid FFS and Encounter, original paid OT claims with the corresponding HCBS service code

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: Waiver 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 WAIVER-PARTICIPATION-ELG00012 by keeping records that satisfy the following criteria: 1a. WAIVER-ENROLLMENT-EFF-DATE <= last day of the DQ report month 2a. WAIVER-ENROLLMENT-END-DATE >= last day of the DQ report month OR missing OR 1b. WAIVER-ENROLLMENT-EFF-DATE is missing 2b. WAIVER-ENROLLMENT-END-DATE is missing STEP 3: Enrollment in 1915(c) waiver Of the MSIS IDs that meet the criteria for STEP 2, further refine the population to MSIS IDs where WAIVER-TYPE-CODE = ("06" - "20", "33") STEP 4: Active non-duplicate paid OT claims during report month Define the OT claims universe at the header 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, 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" STEP 6: Link MSIS IDs from EL to OT Retain the MSIS IDs from STEP 3 that link to an OT claim from STEP 5 STEP 7: Service under 1915(c) HCBS waiver Retain the MSIS IDs from STEP 6 where the HCBS-SERVICE-CODE = "4" STEP 8: MSIS IDs without service under 1915(c) HCBS waiver Subtract the number of unique MSIS IDs in STEP 7 from the number of unique MSIS IDs in STEP 3 STEP 9: Calculate percentage Divide the count of unique MSIS IDs in STEP 8 by the count of unique MSIS IDs in STEP 3