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Measure Name | % of claim headers with PAYMENT-LEVEL-IND = 2 where the sum of Medicaid Paid Amount from the lines does not equal Total Medicaid Paid Amount from the header |
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File Type | CRX |
Measure ID | MCR-59-004-16 |
Measure Type | Claims Percentage |
Content area | MCR |
Validation Type | Inferential |
---|
Measure Priority | High |
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Focus Area | Managed care |
Category | Expenditures |
Claim Type | Medicaid,Enc or CHIP,Enc |
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Adjustment Type | Original |
Crossover Type | All Indicators |
Minimum | 0 |
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Maximum | 0.01 |
TA Minimun | 0 |
TA Maximum | 0.01 |
Longitudinal Threshold | N/A |
For TA
(for including in compliance training) |
TA- Inferential |
For TA
(Longitudinal) |
No |
DD Data Element | MEDICAID-PAID-AMT • TOT-MEDICAID-PAID-AMT |
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DD Data Element Number | CRX125 • CRX041 |
Annotation | Calculate the percentage of Medicaid and S-CHIP Encounter: original, paid RX claims that are paid at the line level where the sum of Medicaid paid amount from the lines does not equal the total Medicaid paid amount from the header |
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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: Medicaid and S-CHIP Encounter: Original, Paid Claims Of the claims that meet the criteria from STEP 1, further restrict them by the following criteria: 1. TYPE-OF-CLAIM = "3" or "C" 2. ADJUSTMENT-IND = "0" STEP 3: Exclude sub-capitation encounters Of the claims that meet the criteria from STEP 2, further restrict them by the following criteria: 1. SOURCE-LOCATION is NOT equal to "22" or "23" STEP 4: Exclude childless headers Of the claim headers that meet the criteria from STEP 3, drop all headers that do not merge to at least one line STEP 5: Claims paid at the line level Of claims that meet the criteria from STEP 4, further restrict them by the following criteria: 1. PAYMENT-LEVEL-IND = "2" STEP 6: Sum Medicaid paid amount from the claim lines Of the claim lines that meet the criteria from STEP 3, sum the MEDICAID-PAID-AMT values to the header level* *Note: Missing values are converted to 0 before calculating the sum STEP 7: Sum does not match total Medicaid paid amount Keep the claims where the sum from STEP 6 does NOT equal the TOT-MEDICAID-PAID-AMT from the header record* *Note: Missing values are converted to 0 before comparison STEP 8: Calculate the percentage for the measure Divide the count of header claims from STEP 7 by the count of header claims from STEP 5. |