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Measure Name | % of claim lines with Medicaid Paid Amount > $100,000 |
---|---|
File Type | COT |
Measure ID | EXP-11-081-3 |
Measure Type | Claims Percentage |
Content area | EXP |
Validation Type | Longitudinal and Inferential |
---|
Measure Priority | Medium |
---|---|
Focus Area | N/A |
Category | Expenditures |
Claim Type | Medicaid,FFS |
---|---|
Adjustment Type | Original |
Crossover Type | Non-Crossover |
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 |
DD Data Element | MEDICAID-PAID-AMT |
---|---|
DD Data Element Number | COT178 |
Annotation | Calculate the percentage of records with amount paid greater than $100,000 for Medicaid FFS: original, non-crossover, paid OT claims |
---|---|
Specification |
STEP 1: Active non-duplicate paid OT claims during 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 Payment: 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 amount paid > $100,000 Of the claims that meet the criteria from STEP 2, count records with MEDICAID-PAID-AMT > 100,000 STEP 4: Calculate the percentage for the measure Divide the count of claims from STEP 3 by the count of claims from STEP 2 |