Official websites use .gov
A
.gov website belongs to an official government
organization in the United States.
Secure .gov websites use HTTPS
A
lock () or https:// means you've safely connected to
the .gov website. Share sensitive information only on official,
secure websites.
Measure Name | % of claim lines on claims where Payment Level Indicator = 2 with Medicaid Paid Amount = $0 or missing, by Plan ID |
---|---|
File Type | COT |
Measure ID | EXP-37P-001-1-2 |
Measure Type | Claims percentage |
Content area | MCR MULTI EXP |
Associated Measure | EXP-37R-001-1-2 |
Validation Type | Inferential |
---|
Measure Priority | N/A |
---|---|
Focus Area | N/A |
Category | N/A |
Claim Type | Medicaid,Enc |
---|---|
Adjustment Type | Original |
Crossover Type | Non-Crossover |
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 |
DD Data Element | MEDICAID-PAID-AMT • PAYMENT-LEVEL-IND |
---|---|
DD Data Element Number | COT178 • COT068 |
Annotation | For each unique Plan ID, calculate the percentage of Medicaid Encounter: original, non-crossover, paid OT claims billed at the line level that have Medicaid paid amount 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 claims during DQ report month Define 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 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. For Lines: 1. Reporting Period from the filename = DQ report month 2. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing 3. 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 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 Encounter: Original, Non-Crossover, Paid Claims Of the claims that meet the criteria from STEP 5, further restrict them by the following criteria: 1. TYPE-OF-CLAIM = "3" 2. ADJUSTMENT-IND = "0" 3. CROSSOVER-INDICATOR = "0" or is missing STEP 8: Exclude sub-capitation encounters Of the claims that meet the criteria from STEP 7, further restrict them by the following criteria: 1. SOURCE-LOCATION is NOT equal to "22" or "23" STEP 9: Payment at the line level Of the claims from STEP 8, select records where: 1. PAYMENT-LEVEL-IND = "2" STEP 10: Total Medicaid paid $0 or missing Of the claims from STEP 9, select records where: 1. TOT-MEDICAID-PAID-AMT = "0" or is missing STEP 11: Calculate the percentage for the measure Divide the count of claims from STEP 10 by the count of claims from STEP 9 STEP 12: Repeat for each Plan_Id REPEAT STEPS 7-11 for each Plan_Id identified in STEP 6 |