Official websites use .gov
A
.gov website belongs to an official government
organization in the United States.
Secure .gov websites use HTTPS
A
lock () or https:// means you've safely connected to
the .gov website. Share sensitive information only on official,
secure websites.
No Updates
Measure Name | % of claim lines with TYPE-OF-SERVICE = 12, 29, 15, 2, 61, 28, 41 where Servicing Provider Number = Billing Provider Number |
---|---|
File Type | COT |
Measure ID | MCR-21-003-2 |
Measure Type | Claims Percentage |
Content area | MCR MULTI PRO |
Validation Type | Inferential |
---|
Measure Priority | Medium |
---|---|
Focus Area | Managed care |
Category | Utilization |
Claim Type | Medicaid,Enc |
---|---|
Adjustment Type | Original |
Crossover Type | Non-Crossover |
Minimum | 0.01 |
---|---|
Maximum | 0.7 |
TA Minimun | 0.0001 |
TA Maximum | 0.8 |
Longitudinal Threshold | N/A |
For TA
(for including in compliance training) |
TA- Inferential |
For TA
(Longitudinal) |
No |
DD Data Element | TYPE-OF-SERVICE • SERVICING-PROV-NUM • BILLING-PROV-NUM |
---|---|
DD Data Element Number | COT186 • COT189 • COT112 |
Annotation | Percentage of unique Medicaid Encounter: original, non-crossover, paid OT claims for TYPE-OF-SERVICE = 12, 29, 15, 2, 61, 28, 41 that have the same service provider ID and billing provider ID |
---|---|
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: Medicaid 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 = "3" 2. ADJUSTMENT-IND = "0" 3. CROSSOVER-INDICATOR = "0" or is missing 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 = "012"or "029" or "015" "002" or "061" or "028" or "041" STEP 4: Same service provider ID and billing provider ID Of the claims that meet the criteria from STEP 3, further restrict them by the following criteria: 1. SERVICING-PROV-NUM = BILLING-PROV-NUM STEP 5: Calculate the percentage for the measure Divide the count of claims from STEP 4 by the count of claims from STEP 3 |