FFS-26-001-1

Data Quality Measure

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Key Information

Measure Name	% of claim headers with a valid Adjustment Indicator (ADJ-IND is 2, 3, 9, other invalid value, or missing)
File Type	CIP
Measure ID	FFS-26-001-1
Measure Type	Claims percentage
Content area	FFS

Validation

Validation Type	Inferential

Measure Priority

Measure Priority	N/A
Focus Area	N/A
Category	N/A

Claim Information

Claim Type	Medicaid,FFS
Adjustment Type	All Adjustment Types
Crossover Type	All Indicators

Thresholds

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

Data Elements

DD Data Element
DD Data Element Number

Annotation	Calculate the percentage of unique header records associated with Medicaid FFS: original and adjustment, paid IP claims with an invalid or missing adjustment indicator value
Specification	STEP 1: Active non-duplicate IP records during DQ report month Define the IP records 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 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 = "1" STEP 3: Total Count Of the claims that meet the criteria from STEP 2, count the number of unique header records. STEP 4: Count invalid adjustment indicators From the records from STEP 2, count unique header records with ADJUSTMENT-IND not equal to ("0", "1", "4", "5", "6") or is missing STEP 5: Percentage Divide the count of unique header records from STEP 4 by the count in STEP 3

Annotation

Calculate the percentage of unique header records associated with Medicaid FFS: original and adjustment, paid IP claims with an invalid or missing adjustment indicator value

Specification

STEP 1: Active non-duplicate IP records during DQ report month

Define the IP records 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 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 = "1"

STEP 3: Total Count

Of the claims that meet the criteria from STEP 2, count the number of unique header records.

STEP 4: Count invalid adjustment indicators

From the records from STEP 2, count unique header records with ADJUSTMENT-IND not equal to ("0", "1", "4", "5", "6") or is missing

STEP 5: Percentage

Divide the count of unique header records from STEP 4 by the count in STEP 3