Key Information

Measure Name	% of SERVICING-PROV-NUM on claim lines 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
File Type	Multiple Files
Measure ID	ALL-21-005-5
Measure Type	Claims Percentage
Content area	ALL MULTI PRO

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,Enc or CHIP,FFS or CHIP,Enc
Adjustment Type	All Adjustment Types
Crossover Type	All Indicators

Thresholds

Minimum	0
Maximum	0.05
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	SERVICING-PROV-NUM • SUBMITTING-STATE-PROV-ID • PROV-MEDICAID-ENROLLMENT-STATUS-CODE • BEGINNING-DATE-OF-SERVICE • PROV-MEDICAID-EFF-DATE • PROV-MEDICAID-END-DATE
DD Data Element Number	CIP260 • PRV097 • PRV100 • CIP243 • PRV098 • PRV099

Annotation

Calculate the percentage of unique servicing provider numbers on Medicaid and S-CHIP FFS and Encounter: original and adjustment, paid IP claim lines that do not have an active record indicating they are a Medicaid-enrolled provider on a claim line date of service

Specification

STEP 1: Active non-duplicate paid IP claims during report month Define the IP 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 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 servicing provider numbers on the claim lines From the claim lines that meet the criteria from STEP 2, create a list of unique SERVICING-PROV-NUM values where: 1. SERVICING-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. SERVICING-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 line is greater than or equal to PROV-MEDICAID-EFF-DATE 4a. BEGINNING-DATE-OF-SERVICE from the claim line 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