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Measure Name | % of claim headers that are crossover claims |
---|---|
File Type | CLT |
Measure ID | ALL-7-001-1 |
Measure Type | Claims Percentage |
Content area | ALL |
Validation Type | Inferential |
---|
Measure Priority | Medium |
---|---|
Focus Area | N/A |
Category | Expenditures |
Claim Type | Medicaid,FFS or Medicaid,Enc |
---|---|
Adjustment Type | Original |
Crossover Type | All Indicators |
Minimum | 0.001 |
---|---|
Maximum | 0.35 |
TA Minimun | 0.001 |
TA Maximum | 0.35 |
Longitudinal Threshold | 0.1 |
For TA
(for including in compliance training) |
TA- Inferential |
For TA
(Longitudinal) |
No |
DD Data Element | CROSSOVER-INDICATOR |
---|---|
DD Data Element Number | CLT023 |
Annotation | The percentage of Medicaid FFS: original, paid LT claims that are crossovers |
---|---|
Specification |
STEP 1: Active non-duplicate LT records during DQ report month Define the LT records universe at the header level that satisfy the following criteria: 1. Reporting Period for 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 FFS and Encounter: Original, 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" 2. ADJUSTMENT-IND = "0" STEP 3: Crossover claims Of the claims that meet the criteria from STEP 2, select records where 1. CROSSOVER-INDICATOR = "1" STEP 4: Calculate the percentage for the measure Divide the count of claims from STEP 3 by the count of claims from STEP 2 |