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TMSIS Dataguide Medicaid.gov
Version 3.38.0

MCR-59P-004-16

Data Quality Measure
Last updated

12/18/2024

Key Information

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 CRX
Measure ID MCR-59P-004-16
Measure Type Claims Percentage
Content area MCR
Associated Measure MCR-59R-004-16

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 0
Maximum 0.01
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 TOT-MEDICAID-PAID-AMT • MEDICAID-PAID-AMT
DD Data Element Number CRX041 • CRX125

Annotation For each unique Plan ID, calculate the percentage of Medicaid and S-CHIP Encounter: original, paid RX 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
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 RX claims during report month

Define the RX 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