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Specification
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STEP 1: Enrolled on the last day of DQ report month
Define the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:
1. ENROLLMENT-EFF-DATE <= last day of the DQ report month
2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing
3. MSIS-IDENTIFICATION-NUM is not missing
STEP 2: Managed care enrollment on the last day of DQ report month
Of the MSIS-IDs that meet the criteria from STEP 1, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:
1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month
2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missing
OR
1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing
2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missing
STEP 3: Managed care plans on the last day of DQ report month
Define the managed care plan population from segment MANAGED-CARE-MAIN-MCR00002 by keeping active records that satisfy the following criteria:
1. MANAGED-CARE-MAIN-REC-EFF-DATE <= last day of the reporting month
2. MANAGED-CARE-MAIN-REC-END-DATE >= last day of the reporting month OR missing
STEP 4: Active non-duplicate claims records during DQ report month
Define the claims universe for IP, LT, and RX at the header level and for OT at the line level by importing headers (and lines for OT) 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, and ADJUDICATION-DATE and ADJUSTMENT-IND=LINE-ADJSTMT-IND.
STEP 5: Medicaid and S-CHIP Capitation Payment and Encounter: Paid Claims
Of the claims that meet the criteria from STEP 4, further restrict them by the following criteria:
1. TYPE-OF-CLAIM = (“2” or "3" or “B” or "C")
STEP 6: Define Plan_Id
Define Plan_Id as a unique list of: MANAGED-CARE-PLAN-ID from the EL file that meet the constraints in STEP 2, STATE-PLAN-ID-NUM from the MCR file that meet the constraints in STEP 3, and PLAN-ID-NUMBER from the claims files that meet the constraints in STEP 5. Also, define a blank Plan_Id for missing.
STEP 7: Define Plan_Type_El
In cases where Plan_Id can be linked to a MANAGED-CARE-PLAN-ID in MANAGED-CARE-PARTICIPATION-ELG00014, and there is only one plan type for that plan, define Plan_Type_El as MANAGED-CARE-PLAN-TYPE. If there are multiple plan types for the Plan_Id, then set Plan_Type_El to the most frequently used plan type, or the lowest plan type if there is a tie. (If there are multiple plan types, also set MultiplePlanTypes_EL = 1.) In all other cases, Plan_Type_El = missing.
STEP 8: Define Plan_Type_Mc and Linked
In cases where Plan_Id can be linked to a STATE-PLAN-ID-NUM in MANAGED-CARE-MAIN-MCR00002, set In_MCR_File = "Yes". If there is only one plan type for that plan, define Plan_Type_Mc as MANAGED-CARE-PLAN-TYPE . If there are multiple plan types for the Plan_Id, then set Plan_Type_Mc to the most frequently used plan type, or the lowest plan type if there is a tie. (If there are multiple plan types, also set MultiplePlanTypes_Mc = 1.) In all other cases, Plan_Type_Mc = missing and In_MCR_File = "No".
STEP 9: Count Enrollment
For each Plan_Id, define Enrollment as the count of unique MSIS-IDENTIFICATION-NUM that satisfy the constraints in STEP 2a
STEPS 10 - 25 apply to records that meet the constraints in STEP 5.
STEP 10: Capitation Claims
Select capitation claims in the OT file by the following criteria:
1. PLAN-ID-NUMBER = Plan_Id
3. MEDICAID-PAID-AMT > 0
4. TYPE-OF-CLAIM = (“2” or “B”)
5. ADJUSTMENT-IND = “0”
STEP 11: Set Capitation Type
Using the records in STEP 10:
1a. Set Capitation_Type = “Medicaid and S-CHIP” if at least one record with TYPE-OF-CLAIM = “2” AND at least one record with TYPE-OF-CLAIM = “B”
1b. Set Capitation_Type = “Medicaid” if at least one record with TYPE-OF-CLAIM = “2” AND no records with TYPE-OF-CLAIM = “B”
1c. Set Capitation_Type = "S-CHIP" if no records with TYPE-OF-CLAIM = “2” AND at least one record with TYPE-OF-CLAIM = “B”
STEP 12: Count Capitation_Hmo_Hio_Pace
Define Capitation_Hmo_Hio_Pace as the count of unique OT line records from STEP 10 that also satisfy the following criteria:
1. TYPE-OF-SERVICE = “119”
STEP 13: Count Capitation_Php
Define Capitation_Php as the count of unique OT line records from STEP 10 that also satisfy the following criteria:
1. TYPE-OF-SERVICE = “122”
STEP 14: Count Capitation_Pccm
Define Capitation_Pccm as the count of unique OT line records from STEP 10 that also satisfy the following criteria:
1. TYPE-OF-SERVICE = “120”
STEP 15: Count Capitation_Phi
Define Capitation_Phi as the count of unique OT line records from STEP 10 that also satisfy the following criteria:
1. TYPE-OF-SERVICE = “121”
STEP 16: Count Capitation_Other
Define Capitation_Other as the count of unique OT line records from STEP 10 that also satisfy the following criteria:
1. TYPE-OF-SERVICE <> (“119”, “120”, “121”, and “122”)
STEP 17: Count Capitation_Total
Define Capitation_Total as the sum of Capitation_Hmo_Hio_Pace, Capitation_Php, Capitation_Pccm, Capitation_Phi, and Capitation_Other
STEP 18: Encounter Claims
Select encounter claims in the IP, LT, OT, and RX files by the following criteria:
1. PLAN-ID-NUMBER = Plan_Id
2. TYPE-OF-CLAIM = (“3” or “C”)
3. ADJUSTMENT-IND = “0”
STEP 19: Set Encounter Type
Using the records in STEP 18:
1a. Set Encounter_Type = “Medicaid and S-CHIP” if at least one record with TYPE-OF-CLAIM = “3” AND at least one record with TYPE-OF-CLAIM = “C”
1b. Set Encounter_Type = “Medicaid” if at least one record with TYPE-OF-CLAIM = “3” AND no records with TYPE-OF-CLAIM = “C”
1c. Set Encounter_Type = "S-CHIP" if no records with TYPE-OF-CLAIM = “3” AND at least one record with TYPE-OF-CLAIM = “C”
STEP 20: Count Encounters_Ip
Define Encounters_Ip as the count of unique IP header records from STEP 18
STEP 21: Count Encounters_Lt
Define Encounters_Lt as the count of unique LT header records from STEP 18
STEP 22: Count Encounters_Ot
Define Encounters_Ot as the count of unique OT line records from STEP 18
STEP 23: Count Encounters_Rx
Define Encounters_Rx as the count of unique RX header records from STEP 18
STEP 24: Count Encounters_Total
Define Encounters_Total as the sum of Encounters_Ip, Encounters_Lt, Encounters_Ot, and Encounters_Rx
STEP 25: Count Ratios
SET Capitation_Ratio = Capitation_Total / Enrollment
SET Encounters_Ip_Ratio = Encounters_Ip / Enrollment
SET Encounters_Lt_Ratio = Encounters_Lt / Enrollment
SET Encounters_Ot_Ratio = Encounters_Ot / Enrollment
SET Encounters_Rx_Ratio = Encounters_Rx / Enrollment
STEP 26: Repeat for each Plan_Id
REPEAT STEPS 7-25 for each Plan_Id identified in STEP 6
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