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TMSIS Dataguide Medicaid.gov
Version 3.28.0

EXP-11-003-83

Data Quality Measure
Last updated

No Updates

Key Information

Measure Name % of amount paid for claim lines with HCBS Taxonomy values beginning with 02, 04, or 08 of the amount for all claim lines with HCBS Taxonomy
File Type COT
Measure ID EXP-11-003-83
Measure Type Ratio
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 0.5
Maximum 0.9
TA Minimun 0.5
TA Maximum 0.9
Longitudinal Threshold 0.3
For TA
(for including in compliance training) 		TA- Inferential
For TA
(Longitudinal) 		No

Data Elements

DD Data Element MEDICAID-PAID-AMT • HCBS-TAXONOMY
DD Data Element Number COT178 • COT188

Annotation Calculate the percentage of Medicaid FFS: original, non-crossover, paid HCBS taxonomy claims that have HCBS taxonomy values beginning with 02, 04, or 08
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: 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: Type of service

Of the line records that meet the criteria from STEP 2, further restrict them by the following criteria:

1. HCBS-TAXONOMY starts with "02", "04", or "08"

2. MEDICAID-PAID-AMT is not missing



STEP 4: Amount paid

1. Of the line records that meet the criteria from STEP 3, sum MEDICAID-PAID-AMT

(this will be the numerator)



STEP 5: All services

Of the line records that meet the criteria from STEP 2, further restrict them by the following criteria:

1. HCBS-TAXONOMY is not missing

2. MEDICAID-PAID-AMT is not missing



STEP 6: Amount paid

Of the line records that meet the criteria from STEP 5, sum MEDICAID-PAID-AMT

(this will be the denominator)



STEP 7: Calculate percentage

Divide the numerator by the denominator