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Measure Name | % of claim headers with TYPE-OF-SERVICE = 45 (nursing facility services for individuals aged 65+ in institutions for mental diseases) without nursing facility days |
---|---|
File Type | CLT |
Measure ID | FFS-5-019-3 |
Measure Type | Claims Percentage |
Content area | FFS |
Validation Type | Longitudinal and Inferential |
---|
Measure Priority | Medium |
---|---|
Focus Area | N/A |
Category | Utilization |
Claim Type | Medicaid,FFS |
---|---|
Adjustment Type | Original |
Crossover Type | Non-Crossover |
Minimum | 0 |
---|---|
Maximum | 0.2 |
TA Minimun | 0 |
TA Maximum | 0.2 |
Longitudinal Threshold | 0.15 |
For TA
(for including in compliance training) |
TA- Inferential |
For TA
(Longitudinal) |
No |
DD Data Element | TYPE-OF-SERVICE • NURSING-FACILITY-DAYS |
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DD Data Element Number | CLT211 • CLT149 |
Annotation | Percentage of Medicaid FFS: original, non-crossover, paid LT claims which were for nursing facility services and have no covered days |
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Specification |
STEP 1: Active non-duplicate LT claims during DQ report month Define the LT claims universe at the header 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 FFS: Original, Non-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. ADJUSTMENT-IND = "0" 3. CROSSOVER-INDICATOR = "0" or is missing STEP 3: Nursing facility records Of the claims that meet the criteria from STEP 2, select those with 1. TYPE-OF-SERVICE = "45" STEP 4: Nursing facility records with zero covered days Of the claims that meet the criteria from STEP 3, select those with 1. NURSING-FACILITY-DAYS = "0" or missing STEP 5 : Calculate percentage for measure Divide the count of claims from STEP 4 by the count of claims from STEP 3. |