04/21/2023 |
3.6.0 |
MCR-59-008-8 |
UPDATE |
Specification |
STEP 1: Active non-duplicate paid RX claims during report monthDefine the RX claims universe at the header level that satisfy the following criteria:1. Reporting Period from the filename = DQ report month2. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing3. CLAIM-DENIED-INDICATOR is not equal to "0" or is missing4. TYPE-OF-CLAIM is not equal to "Z" or is missing5. CLAIM-STATUS is not equal to ("26","026","87","087","542","585", "654") or is missing6. 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 ClaimsOf 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: Non-missing total Medicaid paid and allowed amountsOf the records from STEP 2, further refine the population with the following criteria: 1. TOT-MEDICAID-PAID-AMT is not missing2. TOT-ALLOWED-AMT is not missing3. TOT-ALLOWED-AMT is not equal to 0STEP 4: Total Medicaid paid is greater than total allowed Of the records from STEP 3, further refine the population with the following criteria:1. TOT-MEDICAID-PAID-AMT > TOT-ALLOWED-AMTSTEP 5: PercentageDivide the count of claims from STEP 4 by the count of claims from STEP 3 |
N/A |