Key Information

Measure Name	% of claim headers with Total Medicaid Paid Amount > $2 million
File Type	CIP
Measure ID	EXP-1-012-3
Measure Type	Claims Percentage
Content area	EXP

Validation

Validation Type	Longitudinal and Inferential

Measure Priority

Measure Priority	Medium
Focus Area	N/A
Category	Expenditures

Claim Information

Claim Type	Medicaid,FFS
Adjustment Type	Original
Crossover Type	Non-Crossover

Thresholds

Minimum	0
Maximum	0.01
TA Minimun	0
TA Maximum	0.01
Longitudinal Threshold	0.01
For TA (for including in compliance training)	TA- Inferential
For TA (Longitudinal)	No

Data Elements

DD Data Element	TOT-MEDICAID-PAID-AMT
DD Data Element Number	CIP114

Annotation

Calculate the percentage of Medicaid FFS: original, non-crossover, paid IP claims where the total amount paid to Medicaid is > $2,000,000.00

Specification

STEP 1: Active non-duplicate IP records during DQ report month Define the IP claims universe at the header level that satisfy the following criteria: 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. STEP 2: Medicaid FFS: Original, Non-Crossover, Paid Claims Of the claims that meet the criteria from STEP 1, further restrict them by the following criteria: 1. TYPE-OF-CLAIM = "1" 2. ADJUSTMENT-IND = "0" 3. CROSSOVER-INDICATOR = "0" or is missing STEP 3: Medicaid Paid Amount > $2,000,000 Of the claims that meet the criteria from STEP 2, select records with 1. TOT-MEDICAID-PAID-AMT > $2,000,000 STEP 4: Calculate the percentage for the measure Divide the count of claims from STEP 3 by the count of claims from STEP 2