EXP-11-161-2

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TMSIS Dataguide

Medicaid.gov

Version 3.27.0

EXP-11-161-2

Data Quality Measure

Last updated

Key Information

Measure Name	% of claim lines with Medicaid Paid Amount = $0 or missing
File Type	COT
Measure ID	EXP-11-161-2
Measure Type	Claims Percentage
Content area	EXP

Validation

Validation Type	Longitudinal and Inferential

Measure Priority

Measure Priority	N/A
Focus Area	N/A
Category	N/A

Claim Information

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

Thresholds

Minimum	0
Maximum	0.05
TA Minimun
TA Maximum
Longitudinal Threshold	N/A
For TA (for including in compliance training)	No
For TA (Longitudinal)	No

Data Elements

DD Data Element	MEDICAID-PAID-AMT
DD Data Element Number	COT178

Annotation	N/A
Specification	N/A

Published Date	Data Guide Version	DQM	Action	Field	Before	After
03/10/2023	3.4.0	EXP-11-161-2	UPDATE	Priority	High	N/A
03/10/2023	3.4.0	EXP-11-161-2	UPDATE	Category	Expenditures	N/A
03/10/2023	3.4.0	EXP-11-161-2	UPDATE	For ta comprehensive	TA- Inferential	No
03/10/2023	3.4.0	EXP-11-161-2	UPDATE	For ta inferential	Yes	No
03/10/2023	3.4.0	EXP-11-161-2	UPDATE	Ta min	0
03/10/2023	3.4.0	EXP-11-161-2	UPDATE	Ta max	0.1
03/10/2023	3.4.0	EXP-11-161-2	UPDATE	Longitudinal threshold	0.15	N/A
03/10/2023	3.4.0	EXP-11-161-2	UPDATE	Annotation	The percentage of Medicaid FFS: original, non-crossover, paid OT claim lines that have Medicaid paid amount equal to $0 or missing	N/A
03/10/2023	3.4.0	EXP-11-161-2	UPDATE	Specification	STEP 1: Active non-duplicate OT records during DQ report monthDefine 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 month2. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing3. CLAIM-DENIED-INDICATOR is not equal to "0" or is missing4. TYPE-OF-CLAIM is not equal to "Z" or is missing5. CLAIM-STATUS is not equal to ("26","026","87","087","542","585", "654") or is missing6. 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 month2. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing3. 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 ClaimsOf 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 missingSTEP 3: Medicaid paid $0 or missingOf the claims that meet the criteria from STEP 2, select records with 1. MEDICAID-PAID-AMT = "0" or is missingSTEP 4: Calculate the percentage for the measureDivide the count of claims from STEP 3 by the count of claims from STEP 2	N/A