Key Information

Measure Name	% of MSIS IDs enrolled on Beginning Date of Service
File Type	Multiple Files
Measure ID	MCR-31-003-3
Measure Type	Claims percentage
Content area	MCR

Validation

Validation Type	Inferential

Measure Priority

Measure Priority	N/A
Focus Area	N/A
Category	N/A

Claim Information

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

Thresholds

Minimum	0.95
Maximum	1
TA Minimun
TA Maximum
Longitudinal Threshold	N/A
For TA (for including in compliance training)	No
For TA (Longitudinal)	No

Data Elements

DD Data Element	MSIS-IDENTIFICATION-NUM • BEGINNING-DATE-OF-SERVICE • MSIS-IDENTIFICATION-NUM • ENROLLMENT-EFF-DATE • ENROLLMENT-END-DATE
DD Data Element Number	COT022 • COT033 • ELG251 • ELG253 • ELG254

Annotation

Calculate the percentage of MSIS IDs on Medicaid Capitation Payment: original and adjustment, paid OT claims that can be found on an Eligible file enrollment time span segment that spans the date of service on the claims file

Specification

STEP 1: Active non-duplicate OT records during DQ report month Define the OT records 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 Capitation Payment: 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 = "2" STEP 3: Non-missing beginning date of service Of the claims that meet the criteria from STEP 2, restrict to non-missing BEGINNING-DATE-OF-SERVICE STEP 4: Eligible any time and links to claims Define the ENROLLMENT-TIME-SPAN-ELG00021 file segment records that have an MSIS-ID that links to one of the claims identified in STEP 3 STEP 5: Eligible during date of service Further refine the eligible population by linking on MSIS-ID and keeping records that satisfy the following criteria: 1. Claims BEGINNING-DATE-OF-SERVICE >= ENROLLMENT-EFF-DATE 2. Claims BEGINNING-DATE-OF-SERVICE <= ENROLLMENT-END DATE OR ENROLLMENT-END DATE is missing STEP 6: Unique MSIS-IDs in eligibility From the MSIS-IDs in STEP 5, limit to unique MSIS-IDs STEP 7: Unique MSIS-IDs in claims Of the claims that meet the criteria from STEP 3, limit to unique MSIS-IDs STEP 8: Calculate percentage Divide the count of MSIS-IDs from STEP 6 by the count of MSIS-IDs from STEP 7