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Measure Name | % of service tracking claim headers with a non-zero Total Medicaid Paid Amount |
---|---|
File Type | CRX |
Measure ID | EXP-44-004-4 |
Measure Type | Claims Percentage |
Content area | EXP |
Validation Type | Inferential |
---|
Measure Priority | N/A |
---|---|
Focus Area | N/A |
Category | N/A |
Claim Type | Medicaid,Serv or CHIP,Serv |
---|---|
Adjustment Type | Non-void |
Crossover Type | All Indicators |
Minimum | 0 |
---|---|
Maximum | 0.001 |
TA Minimun | |
TA Maximum | |
Longitudinal Threshold | N/A |
For TA
(for including in compliance training) |
No |
For TA
(Longitudinal) |
No |
DD Data Element | TOT-MEDICAID-PAID-AMT |
---|---|
DD Data Element Number | CRX041 |
Annotation | Calculate the percentage of Medicaid and S-CHIP service tracking, original and adjustment, paid RX claims that have a non zero Total Medicaid Paid Amount |
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Specification |
STEP 1: Active non-duplicate paid RX claims during 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 and S-CHIP Service Tracking: Original and Adjustment, Paid Claims Of the claims that meet the criteria from STEP 1, further restrict them by the following criteria: 1. TYPE-OF-CLAIM = "4" or "D" STEP 3: Non Zero Total Medicaid Paid Amount Of the claims that meet the criteria from STEP 2, further restrict them by the following criteria: 1. TOT-MEDICAID-PAID-AMT is non-zero 2. TOT-MEDICAID-PAID-AMT is not missing STEP 4: Calculate percentage Divide the count of claims from STEP 3 by the count from STEP 2 |