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Measure Name | % of claim headers without a valid Adjustment Indicator (ADJ-IND is 2, 3, 9, other invalid value, or missing) |
---|---|
File Type | CLT |
Measure ID | FFS-26-003-3 |
Measure Type | Claims percentage |
Content area | FFS |
Validation Type | Inferential |
---|
Measure Priority | N/A |
---|---|
Focus Area | N/A |
Category | N/A |
Claim Type | Medicaid,FFS |
---|---|
Adjustment Type | All Adjustment Types |
Crossover Type | All Indicators |
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 |
DD Data Element | |
---|---|
DD Data Element Number |
Annotation | Calculate the percentage of unique header records associated with Medicaid FFS: original and adjustment, paid LT claims with an invalid or missing adjustment indicator value |
---|---|
Specification |
STEP 1: Active non-duplicate LT records during DQ report month Define the LT 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 |