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TMSIS Dataguide Medicaid.gov
Version 3.38.0

MCR-19-007-3

Data Quality Measure
Last updated

No Updates

Key Information

Measure Name % of claim headers with NDC (11 numeric)
File Type CRX
Measure ID MCR-19-007-3
Measure Type Claims Percentage
Content area MCR

Validation

Validation Type Inferential

Measure Priority

Measure Priority High
Focus Area Managed care
Category Utilization

Claim Information

Claim Type CHIP,Enc
Adjustment Type Original
Crossover Type Non-Crossover

Thresholds

Minimum 0.94
Maximum 1
TA Minimun 0.94
TA Maximum 1
Longitudinal Threshold N/A
For TA
(for including in compliance training) 		TA- Inferential
For TA
(Longitudinal) 		No

Data Elements

DD Data Element NATIONAL-DRUG-CODE
DD Data Element Number CRX120

Annotation Percentage of S-CHIP Encounter: original, non-crossover, paid RX claims with NDC
Specification STEP 1: Active non-duplicate paid RX claims during report month

Define the RX claims universe at the header 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 Encounter: Original, Non-Crossover, Paid Claims

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

1. TYPE-OF-CLAIM = "C"

2. ADJUSTMENT-IND = "0"

3. CROSSOVER-INDICATOR = "0" or is missing



STEP 3: National drug code

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

1. NATIONAL-DRUG-CODE character is 11 numeric digits



STEP 4: Calculate the percentage for the measure

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