04/21/2023 |
3.6.0 |
FFS-54-004_1-8 |
UPDATE |
Specification |
STEP 1: Active non-duplicate RX records during DQ report monthDefine the RX records universe at the header level by importing both headers and lines that satisfy the following criteria:For Headers: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.For Lines:1. Reporting Period from the filename = DQ report month2. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing3. 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: Non-void, Crossover, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "1" or "A" 2. CROSSOVER-IND = "1"3. ADJUSTMENT-IND not equal to "1" STEP 3: No Medicare AmountsOf the claims that meet the criteria from STEP 2, further restrict them by the following criteria: 1. MEDICARE-PAID-AMT = 0 or is missing on all lines2. TOT-MEDICARE-COINS-AMT = 0 or is missing3. TOT-MEDICARE-DEDUCTIBLE-AMT = 0 or is missingSTEP 4: Calculate percentageDivide the count of claim headers from STEP 3 by the count of claim headers from STEP 2 |
N/A |