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TMSIS Dataguide Medicaid.gov
Version 3.27.0

FFS-19-002-1

Data Quality Measure
Last updated

No Updates

Key Information

Measure Name % of claim lines with TYPE-OF-SERVICE = 12, 29, 15, 2, 61, 28, 41 where Servicing Provider Number = Billing Provider Number
File Type COT
Measure ID FFS-19-002-1
Measure Type Claims Percentage
Content area MULTI FFS PRO

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 Crossover

Thresholds

Minimum 0.001
Maximum 0.9
TA Minimun 0.001
TA Maximum 0.9
Longitudinal Threshold 0.1
For TA
(for including in compliance training) 		TA- Inferential
For TA
(Longitudinal) 		No

Data Elements

DD Data Element TYPE-OF-SERVICE • SERVICING-PROV-NUM
DD Data Element Number COT186 • COT189

Annotation Percent of unique Medicaid FFS: Original, Crossover, Paid OT claims for TYPE-OF-SERVICE = 12, 29, 15, 2, 61, 28, 41 that have the same service provider ID and billing provider ID
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: 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: Type of Service

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

1. TYPE-OF-SERVICE = (“012” or “029” or “015” or “002” or “061” or “028” or “041”



STEP 4: Service Provider and Billing Provider

Of the claims that meet the criteria from STEP 3, further restrict them by the following criteria:

1. SERVICING-PROV-NUM = BILLING-PROV-NUM



STEP 5: Calculate the percentage for the measure

Divide the count of claims from STEP 4 by the count of claims from STEP 3