03/10/2023 |
3.4.0 |
EXP-39-001-1 |
UPDATE |
Specification |
STEP 1: Active non-duplicate paid OT claims during report monthDefine 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 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.For Lines:1. Reporting Period from the filename = DQ report month2. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing3. 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 2: S-CHIP Encounter: Original, Non-Crossover, Paid ClaimsOf 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 missingSTEP 3: Medicaid paid $0 or missingOf the claims that meet the criteria from STEP 2, restrict to claims that meet the following criteria:1a. MEDICAID-PAID-AMT = "0" or is missingSTEP 4: Calculate percentageDivide the number of claims from STEP 3 by the number of claims from STEP 2. |
N/A |