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TMSIS Dataguide Medicaid.gov
Version 3.38.0

FFS-14-004-5

Data Quality Measure
Last updated

No Updates

Key Information

Measure Name % of claim headers with Days Supply > 30
File Type CRX
Measure ID FFS-14-004-5
Measure Type Claims Percentage
Content area FFS

Validation

Validation Type Longitudinal and Inferential

Measure Priority

Measure Priority Medium
Focus Area N/A
Category Utilization

Claim Information

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

Thresholds

Minimum 0
Maximum 0.15
TA Minimun 0
TA Maximum 0.15
Longitudinal Threshold 0.25
For TA
(for including in compliance training) 		TA- Inferential
For TA
(Longitudinal) 		No

Data Elements

DD Data Element DAYS-SUPPLY
DD Data Element Number CRX138

Annotation Percentage of Medicaid FFS: original, non-crossover, paid RX claims with days of supply greater than 30
Specification STEP 1: Active non-duplicate paid RX claims during report month

Define the RX claims universe at the header 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: Medicaid 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 = "1"

2. ADJUSTMENT-IND = "0"

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



STEP 3: Days of supply

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

1. DAYS-SUPPLY > 30



STEP 4: Calculate the percentage for the measure

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