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Measure Name | % of claim lines with PAYMENT-LEVEL-IND=2 (claim detail) that have Medicaid Paid Amount greater than a non-zero Allowed Amount |
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File Type | CLT |
Measure ID | FFS-49-010-10 |
Measure Type | Claims Percentage |
Content area | FFS |
Validation Type | Inferential |
---|
Measure Priority | Medium |
---|---|
Focus Area | N/A |
Category | Expenditures |
Claim Type | Medicaid,FFS or CHIP,FFS |
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Adjustment Type | Original |
Crossover Type | All Indicators |
Minimum | 0 |
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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 | PAYMENT-LEVEL-IND • MEDICAID-PAID-AMT • ALLOWED-AMT |
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DD Data Element Number | CLT082 • CLT208 • CLT205 |
Annotation | Calculate the percentage of Medicaid and S-CHIP FFS: original, paid LT claim lines with a payment level indicator of 2 where the Medicaid paid amount is greater than the allowed amount |
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Specification |
STEP 1: Active non-duplicate paid LT claims during report month Define the LT claims universe at the line level by importing both headers and lines that satisfy the following criteria: For Headers: 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. For Lines: 1. Reporting Period from the filename = DQ report month 2. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing 3. No Line Duplicates: Duplicates are dropped at the line level if the following data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, LINE-NUM-ORIG, LINE-NUM-ADJ, and LINE-ADJSTMT-IND. 4. Lines merge to a header using ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND=LINE-ADJSTMT-IND. STEP 2: Medicaid and S-CHIP FFS: Original, Paid Claims Of the claims that meet the criteria from STEP 1, further restrict them by the following criteria: 1. TYPE-OF-CLAIM = "1" or "A" 2. ADJUSTMENT-IND = "0" STEP 3: Claim Line Detail Of the claims that meet the criteria from STEP2, further restrict them by the following criteria: 1. PAYMENT-LEVEL-IND = "2" STEP 4: Non-missing Medicaid paid and allowed amounts Of the records from STEP 3, further refine the population with the following criteria: 1. MEDICAID-PAID-AMT is not missing 2. ALLOWED-AMT is not missing 3. ALLOWED-AMT is not equal to 0 STEP 5: Medicaid paid is greater than allowed Of the records from STEP 4, further refine the population with the following criteria: 1. MEDICAID-PAID-AMT > ALLOWED-AMT STEP 6: Percentage Divide the count of claim lines from STEP 5 by the count of claim lines from STEP 4 |