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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, by Plan ID |
---|---|
File Type | CIP |
Measure ID | MCR-59P-001-13 |
Measure Type | Claims Percentage |
Content area | MCR |
Associated Measure | MCR-59R-001-13 |
Validation Type | Inferential |
---|
Measure Priority | N/A |
---|---|
Focus Area | N/A |
Category | N/A |
Claim Type | Medicaid,Enc or CHIP,Enc |
---|---|
Adjustment Type | Original |
Crossover Type | All Indicators |
Minimum | 0 |
---|---|
Maximum | 0.01 |
TA Minimun | |
TA Maximum | |
Longitudinal Threshold | N/A |
For TA
(for including in compliance training) |
No |
For TA
(Longitudinal) |
No |
DD Data Element | TOT-MEDICAID-PAID-AMT • MEDICAID-PAID-AMT |
---|---|
DD Data Element Number | CIP114 • CIP254 |
Annotation | For each unique Plan ID, calculate the percentage of Medicaid and S-CHIP Encounter: original, paid IP 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: Enrolled on the last day of DQ report month Define the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria: 1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing 3. MSIS-IDENTIFICATION-NUM is not missing STEP 2: Managed care enrollment on the last day of DQ report month Of the MSIS-IDs that meet the criteria from STEP 1, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria: 1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month 2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missing OR 1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing 2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missing STEP 3: Managed care plans on the last day of DQ report month Define the managed care plan population from segment MANAGED-CARE-MAIN-MCR00002 by keeping active records that satisfy the following criteria: 1. MANAGED-CARE-MAIN-REC-EFF-DATE <= last day of the reporting month 2. MANAGED-CARE-MAIN-REC-END-DATE >= last day of the reporting month OR missing STEP 4: Active non-duplicate paid IP claims during report month Define the IP 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 5: Medicaid and S-CHIP Capitation Payment and Encounter: Paid Claims Of the claims that meet the criteria from STEP 4, further restrict them by the following criteria: 1. TYPE-OF-CLAIM = (“2” or "3" or “B” or "C") STEP 6: Define Plan_Id Define Plan_Id as a unique list of: MANAGED-CARE-PLAN-ID from the EL file that meet the constraints in STEP 2, STATE-PLAN-ID-NUM from the MCR file that meet the constraints in STEP 3, and PLAN-ID-NUMBER from the claims files that meet the constraints in STEP 5. Also, define a blank Plan_Id for missing. STEP 7: Medicaid and S-CHIP Encounter: Original, Paid Claims Of the claims that meet the criteria from STEP 6, further restrict them by the following criteria: 1. TYPE-OF-CLAIM = "3" or "C" 2. ADJUSTMENT-IND = "0" STEP 8: Exclude sub-capitation encounters Of the claims that meet the criteria from STEP 7, further restrict them by the following criteria: 1. SOURCE-LOCATION is NOT equal to "22" or "23" STEP 9: Exclude childless headers Of the claim headers that meet the criteria from STEP 8, drop all headers that do not merge to at least one line STEP 10: Claims paid at the line level Of claims that meet the criteria from STEP 9, further restrict them by the following criteria: 1. PAYMENT-LEVEL-IND = "2" STEP 11: Sum Medicaid paid amount from the claim lines Of the claim lines that meet the criteria from STEP 8, sum the MEDICAID-PAID-AMT values to the header level* *Note: Missing values are converted to 0 before calculating the sum STEP 12: Sum does not match total Medicaid paid amount Keep the claims where the sum from STEP 11 does NOT equal the TOT-MEDICAID-PAID-AMT from the header record* *Note: Missing values are converted to 0 before comparison STEP 13: Calculate the percentage for the measure Divide the count of claims from STEP 12 by the count of claims from STEP 11 STEP 14: Repeat for each Plan_Id REPEAT STEPS 7-13 for each Plan_Id identified in STEP 6 |