FFS-S-012-10

Data Quality Measure

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Key Information

Measure Name	% of claim headers that are original
File Type	CRX
Measure ID	FFS-S-012-10
Measure Type	Claims Percentage
Content area	FFS

Validation

Validation Type	Longitudinal and Inferential

Measure Priority

Measure Priority	Medium
Focus Area	N/A
Category	Expenditures

Claim Information

Claim Type	Medicaid,FFS
Adjustment Type	All Adjustment Types
Crossover Type	All Indicators

Thresholds

Minimum	0.26
Maximum	0.9999
TA Minimun	0.26
TA Maximum	0.9999
Longitudinal Threshold	0.75
For TA (for including in compliance training)	TA- Inferential
For TA (Longitudinal)	No

Data Elements

DD Data Element	ADJUSTMENT-IND
DD Data Element Number	CRX025

Annotation	Percentage of Medicaid FFS: original and adjustment, paid RX claims that are original
Specification	STEP 1: Active non-duplicate RX claims during DQ report month Define the RX claims universe at the header level that satisfy the following criteria: 1. Reporting Period for 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. STEP 2: Medicaid FFS: Original and Adjustment, Paid Claims Of the claims that meet the criteria from STEP 1, further restrict them by the following criteria: 1. TYPE-OF-CLAIM = "1" STEP 3: Original claims Of the claims that meet the criteria from STEP 2, select records where 1. ADJUSTMENT-IND = "0" STEP 4: Calculate the percentage for the measure Divide the count of claims from STEP 3 by the count of claims from STEP 2

Annotation

Percentage of Medicaid FFS: original and adjustment, paid RX claims that are original

Specification

STEP 1: Active non-duplicate RX claims during DQ report month

Define the RX claims universe at the header level that satisfy the following criteria:

1. Reporting Period for 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.

STEP 2: Medicaid FFS: Original and Adjustment, Paid Claims

Of the claims that meet the criteria from STEP 1, further restrict them by the following criteria:

1. TYPE-OF-CLAIM = "1"

STEP 3: Original claims

Of the claims that meet the criteria from STEP 2, select records where

1. ADJUSTMENT-IND = "0"

STEP 4: Calculate the percentage for the measure

Divide the count of claims from STEP 3 by the count of claims from STEP 2