Key Information

Measure Name	% of claim headers with Total Medicaid Paid Amount = $0 or missing, by Plan ID
File Type	COT
Measure ID	EXP-22P-009-9
Measure Type	Claims percentage
Content area	MCR MULTI EXP
Associated Measure	EXP-22R-009-9

Validation

Validation Type	Longitudinal and Inferential

Measure Priority

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

Claim Information

Claim Type	Medicaid,Cap
Adjustment Type	Original
Crossover Type	All Indicators

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	TOT-MEDICAID-PAID-AMT
DD Data Element Number	COT050

Annotation

For each unique Plan ID, calculate the percentage of Medicaid Capitation Payment: Original, Paid OT claims where total Medicaid paid amount is equal to $0 or missing

Specification

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 OT records during DQ report month Define the OT records universe at the header level that satisfy the following criteria: 1. Reporting Period for 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 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: Medicaid Capitation Payment: Original, Paid Claims Of the claims that meet the criteria from STEP 1, further restrict them by the following criteria: 1. TYPE-OF-CLAIM = "2" 2. ADJUSTMENT-IND = "0" STEP 8: Total Medicaid paid $0 or missing Of the claims from STEP 7, select records where: 1. TOT-MEDICAID-PAID-AMT = "0" or is missing STEP 9: Calculate the percentage for the measure Divide the count of claims from STEP 8 by the count of claims from STEP 7 STEP 10: Repeat for each Plan_Id REPEAT STEPS 7-9 for each Plan_Id identified in STEP 6