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TMSIS Dataguide Medicaid.gov
Version 3.27.0

EXP-31-001-1

Data Quality Measure
Last updated

Key Information

Measure Name % of claim headers with Total Medicaid Paid Amount = $0 or missing
File Type CIP
Measure ID EXP-31-001-1
Measure Type Claims percentage
Content area MCR MULTI EXP

Validation

Validation Type Inferential

Measure Priority

Measure Priority High
Focus Area Managed care
Category Expenditures

Claim Information

Claim Type CHIP,Enc
Adjustment Type Original
Crossover Type Non-Crossover

Thresholds

Minimum 0
Maximum 0.05
TA Minimun 0
TA Maximum 0.1
Longitudinal Threshold 0.2
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 CIP114

Annotation Calculate the percentage of S-CHIP Encounter: original, non-crossover, paid IP claims where total Medicaid paid amount is equal to $0 or missing
Specification STEP 1: Active non-duplicate paid IP claims during report month

Define the IP claims universe at the header level that satisfy the following criteria:

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.



STEP 2: S-CHIP Encounter: 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 = "C"

2. ADJUSTMENT-IND = "0"

3. CROSSOVER-INDICATOR = "0" or is missing



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 that meet the criteria from STEP 3, restrict to claims that meet the following criteria:

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



STEP 5: Calculate percentage

Divide the number of claims from STEP 4 by the number of claims from STEP 3.