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Measure Name | % of crossover claim headers where Total Medicare Deductible Amount and Total Medicare Coinsurance Amount do not sum to Total Medicaid Paid Amount |
---|---|
File Type | CIP |
Measure ID | FFS-43-001-1 |
Measure Type | Claims percentage |
Content area | FFS |
Validation Type | Inferential |
---|
Measure Priority | Medium |
---|---|
Focus Area | N/A |
Category | Expenditures |
Claim Type | Medicaid,FFS |
---|---|
Adjustment Type | All Adjustment Types |
Crossover Type | Crossover |
Minimum | 0 |
---|---|
Maximum | 0.05 |
TA Minimun | 0 |
TA Maximum | 0.05 |
Longitudinal Threshold | N/A |
For TA
(for including in compliance training) |
TA- Inferential |
For TA
(Longitudinal) |
No |
DD Data Element | TOT-MEDICAID-PAID-AMT • TOT-MEDICARE-COINS-AMT • TOT-MEDICARE-DEDUCTIBLE-AMT |
---|---|
DD Data Element Number | CIP114 • CIP117 • CIP116 |
Annotation | The percentage of Medicaid FFS: original and adjustment, crossover, paid IP claims where the sum of the Medicare deductible amount and Medicare coinsurance amount does not equal total Medicaid paid amount |
---|---|
Specification |
STEP 1: Active non-duplicate paid IP claims during report month Define the IP claims universe at the header level that satisfy the following criteria: 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. STEP 2: Medicaid FFS: Original and Adjustment, 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. CROSSOVER-INDICATOR = "1" STEP 3: Total Medicare deductible and coinsurance amount Of the claims that meet the criteria from STEP 2, calculate the sum of TOT-MEDICARE-COINS-AMT* and TOT-MEDICARE-DEDUCTIBLE-AMT* *Note: Missing values are converted to 0 before calculating the sum STEP 4: Claims where total Medicare deductibles and coinsurance amounts do not equal Medicaid paid amounts Count the number of claims where the sum from STEP 3 does NOT equal TOT-MEDICAID-PAID-AMT* *Note: Missing values are converted to 0 before comparison STEP 5: Calculate the percentage for the measure Divide the count from STEP 4 by the count from STEP 2 |