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TMSIS Dataguide Medicaid.gov
Version 3.27.0

FFS-49-012-12

Data Quality Measure
Last updated

No Updates

Key Information

Measure Name % of claim lines with PAYMENT-LEVEL-IND=2 (claim detail) that have Medicaid Paid Amount greater than a non-zero Allowed Amount
File Type CRX
Measure ID FFS-49-012-12
Measure Type Claims Percentage
Content area FFS

Validation

Validation Type Inferential

Measure Priority

Measure Priority N/A
Focus Area N/A
Category N/A

Claim Information

Claim Type Medicaid,FFS or CHIP,FFS
Adjustment Type Original
Crossover Type All Indicators

Thresholds

Minimum N/A
Maximum N/A
TA Minimun
TA Maximum
Longitudinal Threshold N/A
For TA
(for including in compliance training) 		No
For TA
(Longitudinal) 		No

Data Elements

DD Data Element PAYMENT-LEVEL-IND • MEDICAID-PAID-AMT • ALLOWED-AMT
DD Data Element Number CRX058 • CRX125 • CRX122

Annotation Calculate the percent of Medicaid and S-CHIP FFS: original, paid RX claim lines with a payment level indicator of 2 where the Medicaid paid amount is greater than the allowed amount
Specification STEP 1: Active non-duplicate paid RX claims during report month

Define the RX 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