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Specification
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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
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