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TMSIS Dataguide Medicaid.gov
Version 3.27.0

FFS-11-005-21

Data Quality Measure
Last updated

No Updates

Key Information

Measure Name % of claim lines with TYPE-OF-SERVICE = 12, 2, 61, 28, 41 with diagnosis codes
File Type COT
Measure ID FFS-11-005-21
Measure Type Claims Percentage
Content area FFS

Validation

Validation Type Longitudinal and Inferential

Measure Priority

Measure Priority High
Focus Area N/A
Category Utilization

Claim Information

Claim Type CHIP,FFS
Adjustment Type Original
Crossover Type Non-Crossover

Thresholds

Minimum 0.95
Maximum 1
TA Minimun 0.95
TA Maximum 1
Longitudinal Threshold 0.15
For TA
(for including in compliance training) 		TA- Inferential
For TA
(Longitudinal) 		No

Data Elements

DD Data Element TYPE-OF-SERVICE • DIAGNOSIS-CODE-1
DD Data Element Number COT186 • COT027

Annotation Percentage of unique S-CHIP FFS: original, non-crossover, paid OT claims with TYPE-OF-SERVICE = 12, 2, 61, 28, 41 with DX Codes
Specification STEP 1: Active non-duplicate paid OT claims during 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 2: S-CHIP FFS: 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 = "A"

2. ADJUSTMENT-IND = "0"

3. CROSSOVER-INDICATOR = "0" or is missing



STEP 3: Type of service

Of the claim lines that meet the criteria from STEP 2, further restrict them by the following criteria:

1. TYPE-OF-SERVICE = “012” or “002” or “061” or "028" or "041"



STEP 4: Diagnosis code

Of the claims that meet the criteria from STEP 3, select records where

1. DIAGNOSIS-CODE-1 is not 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