MCR-59-009-9

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TMSIS Dataguide

Medicaid.gov

Version 3.28.0

MCR-59-009-9

Data Quality Measure

Last updated

Key Information

Measure Name	% of claim lines with PAYMENT-LEVEL-IND=2 (claim detail) that have Medicaid Paid Amount greater than a non-zero Allowed Amount
File Type	CIP
Measure ID	MCR-59-009-9
Measure Type	Claims Percentage
Content area	MCR

Validation

Validation Type	Inferential

Measure Priority

Measure Priority	Medium
Focus Area	Managed care
Category	Expenditures

Claim Information

Claim Type	Medicaid,Enc or CHIP,Enc
Adjustment Type	Original
Crossover Type	All Indicators

Thresholds

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

Data Elements

DD Data Element	PAYMENT-LEVEL-IND • MEDICAID-PAID-AMT • ALLOWED-AMT
DD Data Element Number	CIP132 • CIP254 • CIP252

Annotation

Calculate the percentage of Medicaid and S-CHIP Encounter: original, paid IP claim lines with a payment level indicator of 2 where the Medicaid paid amount is greater than the allowed amount

Specification

STEP 1: Active non-duplicate paid IP claims during report month

Define the IP claims universe at the line 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: Claim Line Detail

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

1. PAYMENT-LEVEL-IND = "2"

STEP 5: Non-missing Medicaid paid and allowed amounts

Of the records from STEP 4, further refine the population with the following criteria:

1. MEDICAID-PAID-AMT is not missing

2. ALLOWED-AMT is not missing

3. ALLOWED-AMT is not equal to 0

STEP 6: Medicaid paid is greater than allowed

Of the records from STEP 5, further refine the population with the following criteria:

1. MEDICAID-PAID-AMT > ALLOWED-AMT

STEP 7: Percentage

Divide the count of claim lines from STEP 6 by the count of claim lines from STEP 5.

Published Date	Data Guide Version	DQM	Action	Field	Before	After
04/21/2023	3.6.0	MCR-59-009-9	UPDATE	Specification	STEP 1: Active non-duplicate paid IP claims during report monthDefine the IP claims universe at the line level by importing both headers and lines that satisfy the following criteria:For Headers: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.For Lines:1. Reporting Period from the filename = DQ report month2. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing3. 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 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: Claim Line DetailOf the claims that meet the criteria from STEP2, further restrict them by the following criteria:1. PAYMENT-LEVEL-IND = "2"STEP 4: Non-missing Medicaid paid and allowed amountsOf the records from STEP 3, further refine the population with the following criteria: 1. MEDICAID-PAID-AMT is not missing2. ALLOWED-AMT is not missing3. ALLOWED-AMT is not equal to 0STEP 5: Medicaid paid is greater than allowedOf the records from STEP 4, further refine the population with the following criteria:1. MEDICAID-PAID-AMT > ALLOWED-AMTSTEP 6: PercentageDivide the count of claim lines from STEP 5 by the count of claim lines from STEP 4	STEP 1: Active non-duplicate paid IP claims during report monthDefine the IP claims universe at the line level by importing both headers and lines that satisfy the following criteria:For Headers: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.For Lines:1. Reporting Period from the filename = DQ report month2. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing3. 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 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: Exclude sub-capitation encountersOf 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: Claim Line DetailOf the claims that meet the criteria from STEP 3, further restrict them by the following criteria:1. PAYMENT-LEVEL-IND = "2"STEP 5: Non-missing Medicaid paid and allowed amountsOf the records from STEP 4, further refine the population with the following criteria: 1. MEDICAID-PAID-AMT is not missing2. ALLOWED-AMT is not missing3. ALLOWED-AMT is not equal to 0STEP 6: Medicaid paid is greater than allowedOf the records from STEP 5, further refine the population with the following criteria:1. MEDICAID-PAID-AMT > ALLOWED-AMTSTEP 7: PercentageDivide the count of claim lines from STEP 6 by the count of claim lines from STEP 5.