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Measure Name | % of claim headers with Total Medicaid Paid Amount = $0 or missing |
---|---|
File Type | CRX |
Measure ID | EXP-41-001-1 |
Measure Type | Claims percentage |
Content area | MCR MULTI EXP |
Validation Type | Inferential |
---|
Measure Priority | High |
---|---|
Focus Area | Managed care |
Category | Expenditures |
Claim Type | Medicaid,Enc |
---|---|
Adjustment Type | Original |
Crossover Type | Non-Crossover |
Minimum | 0 |
---|---|
Maximum | 0.05 |
TA Minimun | 0 |
TA Maximum | 0.1 |
Longitudinal Threshold | 0.15 |
For TA
(for including in compliance training) |
TA- Inferential |
For TA
(Longitudinal) |
No |
DD Data Element | TOT-MEDICAID-PAID-AMT |
---|---|
DD Data Element Number | CRX041 |
Annotation | The percentage of Medicaid Encounter: original, non-crossover, paid RX claims that have total Medicaid paid amount equal to $0 or missing |
---|---|
Specification |
STEP 1: Active non-duplicate RX records during DQ report month Define the RX 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: Medicaid 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 = "3" 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 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. |