Key Information

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	COT
Measure ID	FFS-45-001-1
Measure Type	Claims percentage
Content area	FFS

Validation

Validation Type	Inferential

Measure Priority

Measure Priority	Medium
Focus Area	N/A
Category	Expenditures

Claim Information

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

Thresholds

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

Data Elements

DD Data Element	TOT-MEDICAID-PAID-AMT • TOT-MEDICARE-COINS-AMT • TOT-MEDICARE-DEDUCTIBLE-AMT
DD Data Element Number	COT050 • COT053 • COT052

Annotation

The percentage of Medicaid FFS: original and adjustment, crossover, paid OT 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 OT claims during report month Define the OT 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