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TMSIS Dataguide Medicaid.gov
Version 3.27.0

MCR-5-019-6

Data Quality Measure
Last updated

No Updates

Key Information

Measure Name % of claim headers with TYPE-OF-SERVICE = 48 (inpatient psychiatric services for individuals under age 21) without inpatient days
File Type CLT
Measure ID MCR-5-019-6
Measure Type Claims Percentage
Content area MCR

Validation

Validation Type Longitudinal and Inferential

Measure Priority

Measure Priority Medium
Focus Area Managed care
Category Utilization

Claim Information

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

Thresholds

Minimum 0
Maximum 0.2
TA Minimun 0
TA Maximum 0.3
Longitudinal Threshold 0.15
For TA
(for including in compliance training) 		TA- Inferential
For TA
(Longitudinal) 		No

Data Elements

DD Data Element TYPE-OF-SERVICE • MEDICAID-COV-INPATIENT-DAYS
DD Data Element Number CLT211 • CLT086

Annotation The percentage of Medicaid Encounter: original, non-crossover, paid LT claims for Inpatient psychiatric services under 21 without IP days
Specification STEP 1: Active non-duplicate paid LT claims during report month

Define the LT 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: 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: Inpatient psychiatric services under 21

Of the claims that meet the criteria from STEP 2, select records where

1. TYPE-OF-SERVICE = "048"



STEP 4: No IP days

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

1a. MEDICAID-COV-INPATIENT-DAYS = "0"

OR

1b. MEDICAID-COV-INPATIENT-DAYS is missing



STEP 5: Calculate the percentage for the measure

Divide the count of claims from STEP 4 by the count of claims from STEP 3