| 06/19/2024 |
3.27.0 |
MCR-13-018-20 |
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 = "122"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 PHP 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 (“05”, “06”, “07”, “08”, “09”, “10”, “11”, “12”, “13”, “14”, “15”, “16”, “18”, “19”) 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 |
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