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TMSIS Dataguide Medicaid.gov
Version 3.27.0

ALL-4-003-3

Data Quality Measure
Last updated

No Updates

Key Information

Measure Name % of billing and servicing provider numbers on claims that are not found in the provider file
File Type Multiple Files
Measure ID ALL-4-003-3
Measure Type Claims percentage
Content area ALL MULTI PRO

Validation

Validation Type Inferential

Measure Priority

Measure Priority High
Focus Area N/A
Category Provider identifiers

Claim Information

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

Thresholds

Minimum 0
Maximum 0.1
TA Minimun 0
TA Maximum 0.1
Longitudinal Threshold N/A
For TA
(for including in compliance training) 		TA- Inferential
For TA
(Longitudinal) 		No

Data Elements

DD Data Element BILLING-PROV-NUM • SERVICING-PROV-NUM • SUBMITTING-STATE-PROV-ID • PROV-IDENTIFIER
DD Data Element Number COT112 • COT189 • PRV019 • PRV081

Annotation Percentage of unique state assigned provider IDs for billing and servicing provider on the OT file that do not match the provider IDs on the provider file
Specification STEP 1: Active non-duplicate OT records during DQ 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 2: Unique state-assigned provider IDs

For each of the OT claims identified in STEP 1, create a list of unique state-assigned provider IDs using the following data elements:

1. BILLING-PROV-NUM

2. SERVICING-PROV-NUM



STEP 3: Match state-assigned provider IDs to provider file IDs

Match the unique state assigned provider IDs identified in STEP 2 to the SUBMITTING-STATE-PROV-ID in the PROV-ATTRIBUTES-MAIN-PRV00002 segment OR the PROV-IDENTIFIER in the PROV-IDENTIFIERS-PRV00005 segment



STEP 4: Number of non-matches

Count the number of unique state assigned provider IDs from STEP 2 that fail to match in STEP 3



STEP 5: Percentage of non-matches

Divide the count from STEP 4 by the total number of unique state assigned provider IDs identified in STEP 2