Key Information

Measure Name	% of claim headers with Total Medicaid Paid Amount = $0 or missing
File Type	COT
Measure ID	EXP-28-001-1
Measure Type	Claims Percentage
Content area	EXP

Validation

Validation Type	Longitudinal and Inferential

Measure Priority

Measure Priority	High
Focus Area	N/A
Category	Expenditures

Claim Information

Claim Type	CHIP,FFS
Adjustment Type	Original
Crossover Type	Crossover

Thresholds

Minimum	0
Maximum	0.3
TA Minimun	0
TA Maximum	0.4
Longitudinal Threshold	0.1
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	COT050

Annotation

Calculate the percentage of S-CHIP FFS: original, crossover, paid OT claims where total Medicaid paid amount is equal to $0 or missing

Specification

STEP 1: 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 2: S-CHIP FFS: Original, Crossover, Paid Claims Of the claims that meet the criteria from STEP 1, further restrict them by the following criteria: 1. TYPE-OF-CLAIM = "A" 2. ADJUSTMENT-IND = "0" 3. CROSSOVER-INDICATOR = "1" STEP 3: Total Medicaid paid $0 or missing Of the claims that meet the criteria from STEP 2, restrict to claims that meet the following criteria: 1. TOT-MEDICAID-PAID-AMT = "0" or is missing STEP 4: Calculate percentage Divide the number of claims from STEP 3 by the number of claims from STEP 2.