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TMSIS Dataguide Medicaid.gov
Version 3.27.0

ALL-8-001-1

Data Quality Measure
Last updated

No Updates

Key Information

Measure Name % of claim lines that are crossover claims
File Type COT
Measure ID ALL-8-001-1
Measure Type Claims Percentage
Content area ALL

Validation

Validation Type Inferential

Measure Priority

Measure Priority Medium
Focus Area N/A
Category Expenditures

Claim Information

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

Thresholds

Minimum 0.05
Maximum 0.35
TA Minimun 0.05
TA Maximum 0.35
Longitudinal Threshold 0.25
For TA
(for including in compliance training) 		TA- Inferential
For TA
(Longitudinal) 		No

Data Elements

DD Data Element CROSSOVER-INDICATOR
DD Data Element Number COT023

Annotation The percentage of Medicaid FFS: original, paid OT claims that are crossovers
Specification STEP 1: Active non-duplicate OT claims 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: 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