EXP-30-001-1

Key Information

Measure Name	% of claim headers with Total Medicaid Paid Amount = $0 or missing
File Type	CIP
Measure ID	EXP-30-001-1
Measure Type	Claims percentage
Content area	MCR MULTI EXP

Measure Name

% of claim headers with Total Medicaid Paid Amount = $0 or missing

File Type

CIP

Measure ID

EXP-30-001-1

Measure Type

Claims percentage

Content area

MCR MULTI EXP

Validation

Validation Type	Inferential

Validation Type

Inferential

Measure Priority

Measure Priority	High
Focus Area	Managed care
Category	Expenditures

High

Focus Area

Managed care

Category

Expenditures

Claim Information

Claim Type	Medicaid,Enc
Adjustment Type	Original
Crossover Type	Crossover

Claim Type

Medicaid,Enc

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

Minimum

Maximum

0.3

TA Minimun

TA Maximum

0.4

Longitudinal Threshold

0.1

For TA
(for including in compliance training)

TA- Inferential

For TA
(Longitudinal)

Data Elements

DD Data Element	TOT-MEDICAID-PAID-AMT
DD Data Element Number	CIP114

DD Data Element

TOT-MEDICAID-PAID-AMT

DD Data Element Number

CIP114

Annotation	The percentage of Medicaid Encounter: original, crossover, paid IP claims that have total Medicaid paid amount equal to $0 or missing
Specification	STEP 1: Active non-duplicate IP records during DQ report month Define the IP 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: Medicaid Encounter: 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 = "3" 2. ADJUSTMENT-IND = "0" 3. CROSSOVER-INDICATOR = "1" STEP 3: Exclude sub-capitation encounters Of the claims that meet the criteria from STEP 2, further restrict them by the following criteria: 1. SOURCE-LOCATION is NOT equal to "22" or "23" STEP 4: Total Medicaid paid $0 or missing Of the claims from STEP 3, select records where: 1. TOT-MEDICAID-PAID-AMT = "0" or is missing STEP 5: Calculate the percentage for the measure Divide the count of claims from STEP 4 by the count of claims from STEP 3

Annotation

The percentage of Medicaid Encounter: original, crossover, paid IP claims that have total Medicaid paid amount equal to $0 or missing

Specification

STEP 1: Active non-duplicate IP records during DQ report month

Define the IP 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: Medicaid Encounter: 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 = "3"

2. ADJUSTMENT-IND = "0"

3. CROSSOVER-INDICATOR = "1"

STEP 3: Exclude sub-capitation encounters

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

1. SOURCE-LOCATION is NOT equal to "22" or "23"

STEP 4: Total Medicaid paid $0 or missing

Of the claims from STEP 3, select records where:

1. TOT-MEDICAID-PAID-AMT = "0" or is missing

STEP 5: Calculate the percentage for the measure

Divide the count of claims from STEP 4 by the count of claims from STEP 3

Published Date	Data Guide Version	DQM	Action	Field	Before	After
04/21/2023	3.6.0	EXP-30-001-1	UPDATE	Specification	STEP 1: Active non-duplicate IP records during DQ report monthDefine the IP records universe at the header level that satisfy the following criteria:1. Reporting Period for 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.STEP 2: Medicaid Encounter: Original, Crossover, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "3"2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "1"STEP 3: Total Medicaid paid $0 or missingOf the claims from STEP 2, select records where:1. TOT-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	STEP 1: Active non-duplicate IP records during DQ report monthDefine the IP records universe at the header level that satisfy the following criteria:1. Reporting Period for 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.STEP 2: Medicaid Encounter: Original, Crossover, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "3"2. ADJUSTMENT-IND = "0"3. CROSSOVER-INDICATOR = "1"STEP 3: Exclude sub-capitation encountersOf the claims that meet the criteria from STEP 2, further restrict them by the following criteria:1. SOURCE-LOCATION is NOT equal to "22" or "23"STEP 4: Total Medicaid paid $0 or missingOf the claims from STEP 3, select records where:1. TOT-MEDICAID-PAID-AMT = "0" or is missingSTEP 5: Calculate the percentage for the measureDivide the count of claims from STEP 4 by the count of claims from STEP 3