MCR-13-006

MCR-13-006_1-18

Data Quality Measure

Last updated

Key Information

Measure Name	% of PCCM (TYPE-OF-SERVICE) capitation payments with a non-missing plan ID that do not have a corresponding managed care participation PCCM plan
File Type	Multiple Files
Measure ID	MCR-13-006_1-18
Measure Type	Claims percentage
Content area	MCR

Validation

Validation Type	Inferential

Measure Priority

Measure Priority	Medium
Focus Area	Managed care
Category	Expenditures

Claim Information

Claim Type	CHIP,Cap
Adjustment Type	Original
Crossover Type	All Indicators

Thresholds

Minimum	0
Maximum	0.05
TA Minimun	0
TA Maximum	0.05
Longitudinal Threshold	N/A
For TA (for including in compliance training)	TA- Inferential
For TA (Longitudinal)	No

Data Elements

DD Data Element	TYPE-OF-SERVICE • PLAN-ID-NUMBER • MANAGED-CARE-PLAN-ID • MSIS-IDENTIFICATION-NUM • MSIS-IDENTIFICATION-NUM • MANAGED-CARE-PLAN-TYPE
DD Data Element Number	COT186 • COT066 • ELG192 • COT022 • ELG191 • ELG193

Annotation	Calculate the percentage of PCCM capitation payments with a non-missing plan ID that do not have a corresponding managed care participation PCCM plan
Specification	STEP 1: Active non-duplicate paid OT claims during report month Define the OT 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: S-CHIP Capitation Payment: Original, Paid Claims Of the claims that meet the criteria from STEP 1, further restrict them by the following criteria: 1. TYPE-OF-CLAIM = "B" 2. ADJUSTMENT-IND = "0" STEP 3: Type of service Of the claims that meet the criteria from STEP 2, further restrict them by the following criteria: 1. TYPE-OF-SERVICE = "120" STEP 4: Non-missing plan id Of the claims that meet the criteria from STEP 3, further restrict them by the following criteria: 1. PLAN-ID-NUMBER is not missing STEP 5: Enrolled on the last day of DQ report month Define the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria: 1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing 3. MSIS-IDENTIFICATION-NUM is not missing STEP 6: Managed care enrollment on the last day of DQ report month Of the MSIS-IDs that meet the criteria from STEP 5, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria: 1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month 2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missing OR 1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing 2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missing STEP 7: No managed care participation PCCM plan Of the claim lines that meet the criteria from STEP 4, further restrict them by attempting to merge them with the data from STEP 6 and keeping those that satisfy the following criteria: 1a. PLAN-ID-NUMBER = MANAGED-CARE-PLAN-ID 2a. MSIS-IDENTIFICATION-NUM matches 3a. MANAGED-CARE-PLAN-TYPE does NOT equal "02" or "03" for any records where 1a and 2a are satisfied OR It is not the case that: 1b. PLAN-ID-NUMBER = MANAGED-CARE-PLAN-ID 2b. MSIS-IDENTIFICATION-NUM matches STEP 8: Calculate the percentage for the measure Divide the count of claims from STEP 7 by the count of claims from STEP 4

Annotation

Calculate the percentage of PCCM capitation payments with a non-missing plan ID that do not have a corresponding managed care participation PCCM plan

Specification

STEP 1: Active non-duplicate paid OT claims during report month

Define the OT 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: S-CHIP Capitation Payment: Original, Paid Claims

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

1. TYPE-OF-CLAIM = "B"

2. ADJUSTMENT-IND = "0"

STEP 3: Type of service

Of the claims that meet the criteria from STEP 2, further restrict them by the following criteria:

1. TYPE-OF-SERVICE = "120"

STEP 4: Non-missing plan id

Of the claims that meet the criteria from STEP 3, further restrict them by the following criteria:

1. PLAN-ID-NUMBER is not missing

STEP 5: Enrolled on the last day of DQ report month

Define the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:

1. ENROLLMENT-EFF-DATE <= last day of the DQ report month

2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing

3. MSIS-IDENTIFICATION-NUM is not missing

STEP 6: Managed care enrollment on the last day of DQ report month

Of the MSIS-IDs that meet the criteria from STEP 5, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:

1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month

2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missing

OR

1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing

2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missing

STEP 7: No managed care participation PCCM plan

Of the claim lines that meet the criteria from STEP 4, further restrict them by attempting to merge them with the data from STEP 6 and keeping those that satisfy the following criteria:

1a. PLAN-ID-NUMBER = MANAGED-CARE-PLAN-ID

2a. MSIS-IDENTIFICATION-NUM matches

3a. MANAGED-CARE-PLAN-TYPE does NOT equal "02" or "03" for any records where 1a and 2a are satisfied

OR

It is not the case that:

1b. PLAN-ID-NUMBER = MANAGED-CARE-PLAN-ID

2b. MSIS-IDENTIFICATION-NUM matches

STEP 8: Calculate the percentage for the measure

Divide the count of claims from STEP 7 by the count of claims from STEP 4

Published Date	Data Guide Version	DQM	Action	Field	Before	After
04/21/2023	3.6.0	MCR-13-006_1-18	UPDATE	Measure name	% of PCCM (TYPE-OF-SERVICE) capitated payments with a non-missing plan ID that do not have a corresponding managed care participation PCCM plan	% of PCCM (TYPE-OF-SERVICE) capitation payments with a non-missing plan ID that do not have a corresponding managed care participation PCCM plan
04/21/2023	3.6.0	MCR-13-006_1-18	UPDATE	Annotation	Calculate the percentage of PCCM capitated payments with a non-missing plan id that do not have a corresponding managed care participation PCCM plan	Calculate the percentage of PCCM capitation payments with a non-missing plan ID that do not have a corresponding managed care participation PCCM plan
04/21/2023	3.6.0	MCR-13-006_1-18	UPDATE	Specification	STEP 1: Active non-duplicate paid OT claims during report monthDefine the OT 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 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: S-CHIP Capitation Payment: Original, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "B"2. ADJUSTMENT-IND = "0"STEP 3: Type of serviceOf the claims that meet the criteria from STEP 2, further restrict them by the following criteria: 1. TYPE-OF-SERVICE = "120"STEP 4: Non-missing plan idOf the claims that meet the criteria from STEP 3, further restrict them by the following criteria: 1. PLAN-ID-NUMBER is not missingSTEP 5: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 6: Managed care enrollment on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 5, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 7: No managed care participation PCCM planOf the claim lines that meet the criteria from STEP 4, further restrict them by attempting to merge them with the data from STEP 6 and keeping those that satisfy the following criteria:1a. PLAN-ID-NUMBER = MANAGED-CARE-PLAN-ID2a. MSIS-IDENTIFICATION-NUM matches 3a. MANAGED-CARE-PLAN-TYPE does NOT equal "02" for any records where 1a and 2a are satisfiedORIt is not the case that:1b. PLAN-ID-NUMBER = MANAGED-CARE-PLAN-ID2b. MSIS-IDENTIFICATION-NUM matches STEP 8: Calculate the percentage for the measureDivide the count of claims from STEP 7 by the count of claims from STEP 4	STEP 1: Active non-duplicate paid OT claims during report monthDefine the OT 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 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: S-CHIP Capitation Payment: Original, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "B"2. ADJUSTMENT-IND = "0"STEP 3: Type of serviceOf the claims that meet the criteria from STEP 2, further restrict them by the following criteria: 1. TYPE-OF-SERVICE = "120"STEP 4: Non-missing plan idOf the claims that meet the criteria from STEP 3, further restrict them by the following criteria: 1. PLAN-ID-NUMBER is not missingSTEP 5: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 6: Managed care enrollment on the last day of DQ report monthOf the MSIS-IDs that meet the criteria from STEP 5, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 7: No managed care participation PCCM planOf the claim lines that meet the criteria from STEP 4, further restrict them by attempting to merge them with the data from STEP 6 and keeping those that satisfy the following criteria:1a. PLAN-ID-NUMBER = MANAGED-CARE-PLAN-ID2a. MSIS-IDENTIFICATION-NUM matches 3a. MANAGED-CARE-PLAN-TYPE does NOT equal "02" or "03" for any records where 1a and 2a are satisfiedORIt is not the case that:1b. PLAN-ID-NUMBER = MANAGED-CARE-PLAN-ID2b. MSIS-IDENTIFICATION-NUM matches STEP 8: Calculate the percentage for the measureDivide the count of claims from STEP 7 by the count of claims from STEP 4