EXP-7-027-2

Data Quality Measure

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Key Information

Measure Name	% of claim headers with Total Medicaid Paid Amount = $0 or missing
File Type	CLT
Measure ID	EXP-7-027-2
Measure Type	Claims Percentage
Content area	EXP

Validation

Validation Type	Longitudinal and Inferential

Measure Priority

Measure Priority	High
Focus Area	N/A
Category	Expenditures

Claim Information

Claim Type	Medicaid,FFS
Adjustment Type	Original
Crossover Type	Crossover

Thresholds

Minimum	0
Maximum	0.3
TA Minimun	0
TA Maximum	0.4
Longitudinal Threshold	0.1
For TA (for including in compliance training)	TA- Inferential
For TA (Longitudinal)	No

Data Elements

DD Data Element	TOT-MEDICAID-PAID-AMT
DD Data Element Number	CLT065

Annotation	The percentage of Medicaid FFS: original, crossover, paid LT claims that have total Medicaid paid amount equal to $0 or missing
Specification	STEP 1: Active non-duplicate LT claims during DQ report month Define the LT claims universe at the header level that satisfy the following criteria: 1. Reporting Period for 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 FFS: Original, Crossover, Paid Claims Of the claims that meet the criteria from STEP 1, further restrict them by the following criteria: 1. TYPE-OF-CLAIM = "1" 2. ADJUSTMENT-IND = "0" 3. CROSSOVER-INDICATOR = "1" STEP 3: Total Medicaid paid $0 or missing Of the claims that meet the criteria from STEP 2, select records with 1. TOT-MEDICAID-PAID-AMT = "0" or is missing STEP 4: Calculate the percentage for the measure Divide the count of claims from STEP 3 by the count of claims from STEP 2

Annotation

The percentage of Medicaid FFS: original, crossover, paid LT claims that have total Medicaid paid amount equal to $0 or missing

Specification

STEP 1: Active non-duplicate LT claims during DQ report month

Define the LT claims universe at the header level that satisfy the following criteria:

1. Reporting Period for 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 FFS: Original, Crossover, Paid Claims

Of the claims that meet the criteria from STEP 1, further restrict them by the following criteria:

1. TYPE-OF-CLAIM = "1"

2. ADJUSTMENT-IND = "0"

3. CROSSOVER-INDICATOR = "1"

STEP 3: Total Medicaid paid $0 or missing

Of the claims that meet the criteria from STEP 2, select records with

1. TOT-MEDICAID-PAID-AMT = "0" or is missing

STEP 4: Calculate the percentage for the measure

Divide the count of claims from STEP 3 by the count of claims from STEP 2