11/15/2023 |
3.16.0 |
FFS-47-001-1 |
UPDATE |
Specification |
STEP 1: Active non-duplicate IP records during DQ report monthDefine the IP records universe at the header level that satisfy the following criteria:1. Reporting Period for the filename = DQ report month2. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing3. CLAIM-DENIED-INDICATOR is not equal to "0" or is missing4. TYPE-OF-CLAIM is not equal to "Z" or is missing5. CLAIM-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing6. 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 ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "1"STEP 3: Patient status is not "Still a Patient"Of the claims that meet the criteria from STEP 2, further restrict them by the following criteria: 1. PATIENT-STATUS is not equal to "30"2. PATIENT-STATUS is not missingSTEP 4: Missing discharge dateOf the claims from STEP 3, select records where:1. DISCHARGE-DATE is missingSTEP 5: Calculate percentageDivide the number of claims from STEP 4 by the number of claims from STEP 3 |
N/A |