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Measure Name | % of BILLING-PROV-NUM on claim headers that do not have a match in PRV00007 with active provider enrollment status (PROV-MEDICAID-ENROLLMENT-STATUS-CODE in (1, 2, 3, 4, 5, 6) on Beginning Date of Service |
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File Type | Multiple Files |
Measure ID | ALL-21-002-2 |
Measure Type | Claims Percentage |
Content area | ALL MULTI PRO |
Validation Type | Inferential |
---|
Measure Priority | N/A |
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Focus Area | N/A |
Category | N/A |
Claim Type | Medicaid,FFS or Medicaid,Enc or CHIP,FFS or CHIP,Enc |
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Adjustment Type | All Adjustment Types |
Crossover Type | All Indicators |
Minimum | 0 |
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Maximum | 0.05 |
TA Minimun | |
TA Maximum | |
Longitudinal Threshold | N/A |
For TA
(for including in compliance training) |
No |
For TA
(Longitudinal) |
No |
DD Data Element | BILLING-PROV-NUM • SUBMITTING-STATE-PROV-ID • PROV-MEDICAID-ENROLLMENT-STATUS-CODE • BEGINNING-DATE-OF-SERVICE • PROV-MEDICAID-EFF-DATE • PROV-MEDICAID-END-DATE |
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DD Data Element Number | CLT130 • PRV097 • PRV100 • CLT048 • PRV098 • PRV099 |
Annotation | Calculate the percentage of unique billing provider numbers on Medicaid and S-CHIP FFS and Encounter: original and adjustment, paid LT claims that do not have an active record indicating they are a Medicaid-enrolled provider on a claim date of service |
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Specification |
STEP 1: Active non-duplicate paid LT claims during report month Define the LT claims universe at the header level that satisfy the following criteria: 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. STEP 2: Medicaid and S-CHIP FFS and Encounter: Original and Adjustment, Paid Claims Of the claims that meet the criteria from STEP 1, further restrict them by the following criteria: 1. TYPE-OF-CLAIM = "1" or "3" or "A" or "C" STEP 3: Unique billing provider numbers on the claims From the claims that meet the criteria from STEP 2, create a list of unique BILLING-PROV-NUM values where: 1. BILLING-PROV-NUM is not missing STEP 4: Providers without enrollment on the date of service Of the unique provider identifiers from STEP 3, refine the list using PROV-MEDICAID-ENROLLMENT-PRV00007 by keeping providers that do not meet all of the following criteria for all claims: 1. BILLING-PROV-NUM found in SUBMITTING-STATE-PROV-ID 2. PROV-MEDICAID-ENROLLMENT-STATUS-CODE = ("1" or "01") or ("2" or "02") or ("3" or "03") or ("4" or "04") or ("5" or "05") or ("6" or "06") 3. BEGINNING-DATE-OF-SERVICE from the claim is greater than or equal to PROV-MEDICAID-EFF-DATE 4a. BEGINNING-DATE-OF-SERVICE from the claim is less than or equal to PROV-MEDICAID-END-DATE OR 4b. PROV-MEDICAID-END-DATE is missing STEP 5: Calculate percentage Divide the count of unique providers from STEP 4 by the count from STEP 3 |