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Measure Name | % of claim headers that have Total Medicaid Paid Amount greater than a non-zero Total Allowed Amount |
---|---|
File Type | CLT |
Measure ID | MCR-59-006-6 |
Measure Type | Claims Percentage |
Content area | MCR |
Validation Type | Inferential |
---|
Measure Priority | High |
---|---|
Focus Area | Managed care |
Category | Expenditures |
Claim Type | Medicaid,Enc or CHIP,Enc |
---|---|
Adjustment Type | Original |
Crossover Type | All Indicators |
Minimum | 0 |
---|---|
Maximum | 0.05 |
TA Minimun | 0 |
TA Maximum | 0.05 |
Longitudinal Threshold | N/A |
For TA
(for including in compliance training) |
TA- Inferential |
For TA
(Longitudinal) |
No |
DD Data Element | TOT-MEDICAID-PAID-AMT • TOT-ALLOWED-AMT |
---|---|
DD Data Element Number | CLT065 • CLT064 |
Annotation | Calculate the percentage of Medicaid and S-CHIP Encounter: original, paid LT claims where the total Medicaid paid amount is greater than the total allowed amount |
---|---|
Specification |
STEP 1: Active non-duplicate LT records during DQ report month Define the LT 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 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: Non-missing total Medicaid paid and allowed amounts Of the records from STEP 3, further refine the population with the following criteria: 1. TOT-MEDICAID-PAID-AMT is not missing 2. TOT-ALLOWED-AMT is not missing 3. TOT-ALLOWED-AMT is not equal to 0 STEP 5: Total Medicaid paid is greater than total allowed Of the records from STEP 4, further refine the population with the following criteria: 1. TOT-MEDICAID-PAID-AMT > TOT-ALLOWED-AMT STEP 6: Percentage Divide the count of claims from STEP 5 by the count of claims from STEP 4. |