MCR-59-012-12

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TMSIS Dataguide

Medicaid.gov

Version 3.27.0

MCR-59-012-12

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	CRX
Measure ID	MCR-59-012-12
Measure Type	Claims Percentage
Content area	MCR

Validation

Validation Type	Inferential

Measure Priority

Measure Priority	N/A
Focus Area	N/A
Category	N/A

Claim Information

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

Thresholds

Minimum	N/A
Maximum	N/A
TA Minimun
TA Maximum
Longitudinal Threshold	N/A
For TA (for including in compliance training)	No
For TA (Longitudinal)	No

Data Elements

DD Data Element	PAYMENT-LEVEL-IND • MEDICAID-PAID-AMT • ALLOWED-AMT
DD Data Element Number	CRX058 • CRX125 • CRX122

Annotation	N/A
Specification	N/A

Published Date	Data Guide Version	DQM	Action	Field	Before	After
04/21/2023	3.6.0	MCR-59-012-12	UPDATE	Annotation	Calculate the percentage of Medicaid and S-CHIP Encounter: original, paid RX claim lines with a payment level indicator of 2 where the Medicaid paid amount is greater than the allowed amount	N/A
04/21/2023	3.6.0	MCR-59-012-12	UPDATE	Specification	STEP 1: Active non-duplicate paid RX claims during report monthDefine the RX 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	N/A