FFS-50-008-8

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TMSIS Dataguide

Medicaid.gov

Version 3.27.0

FFS-50-008-8

Data Quality Measure

Last updated

Key Information

Measure Name	% of claim headers with Billing Provider NPI Number in an invalid format
File Type	CRX
Measure ID	FFS-50-008-8
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
Adjustment Type	All Adjustment Types
Crossover Type	All Indicators

Thresholds

Minimum	0
Maximum	0.01
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	BILLING-PROV-NPI-NUM
DD Data Element Number	CRX071

Annotation	N/A
Specification	N/A

Published Date	Data Guide Version	DQM	Action	Field	Before	After
06/19/2024	3.27.0	FFS-50-008-8	UPDATE	Priority	High	N/A
06/19/2024	3.27.0	FFS-50-008-8	UPDATE	Category	Provider information	N/A
06/19/2024	3.27.0	FFS-50-008-8	UPDATE	For ta comprehensive	TA- Inferential	No
06/19/2024	3.27.0	FFS-50-008-8	UPDATE	For ta inferential	Yes	No
06/19/2024	3.27.0	FFS-50-008-8	UPDATE	Ta min	0
06/19/2024	3.27.0	FFS-50-008-8	UPDATE	Ta max	0.01
06/19/2024	3.27.0	FFS-50-008-8	UPDATE	Annotation	Calculate the percentage Medicaid FFS: original and adjustment, paid RX claims with an invalid billing provider NPI number	N/A
06/19/2024	3.27.0	FFS-50-008-8	UPDATE	Specification	STEP 1: Active non-duplicate paid RX claims during report monthDefine the RX claims universe at the header level that satisfy the following criteria:1. Reporting Period from 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: Non-missing billing provider NPI numberOf the claims that meet the criteria from STEP 2, restrict to claims with a non-missing BILLING-PROV-NPI-NUMSTEP 4: Calculate Luhn check digitOf the claims that meet the criteria from STEP 3, follow the steps below to calculate the Luhn check digit: 1. Ensure that BILLING-PROV-NPI-NUM only contains digits 0-9.2. Ensure that BILLING-PROV-NPI-NUM has length 10.3. Using BILLING-PROV-NPI-NUM, double the digits in slots 1, 3, 5, 7, and 9. 4. If the doubling of the digits results in a number that is greater than or equal to 10, split the digits. For example, 14 becomes 1 and 4. 5. Add the digits from step 4 to the digits in slots 2, 4, 6, and 8.6. Add 24 to the sum from step 5. 7. Round the result from step 6 up to the nearest 10s place.8. Subtract the result from step 6 from the result in step 7.Example: Billing Provider NPI Num = 12345678931. Passes check2. Passes check3. Double odd-slotted digits: 2 6 10 14 18 4. Split digits 10 and over: 2 6 1 0 1 4 1 85. Add digits from above and even-slotted digits: 2 + 6 + 1 + 0 + 1 + 4 + 1 + 8 + 2 + 4 + 6 + 8 = 43. 6. Add 24: 24 + 43 = 67 7. Round up: 67 rounds up to 708. Subtract: 70 - 67 = 3STEP 5: Invalid billing provider NPI numberOf the claims that meet the criteria from STEP 4, keep those that meet the following criteria: 1a. Luhn check digit from STEP 4 does not equal 10th digit of BILLING-PROV-NPI-NUMOR1b. BILLING-PROV-NPI-NUM does not begin with “1”STEP 6: Calculate percentDivide the count from STEP 5 from STEP 3	N/A