06/19/2024 |
3.27.0 |
MCR-60-008-8 |
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 Encounter: Original and Adjustment, Paid ClaimsOf the claims that meet the criteria from STEP 1, further restrict them by the following criteria:1. TYPE-OF-CLAIM = "3"STEP 3: Non-missing billing provider NPI numberOf the claims that meet the criteria from STEP 2, restrict to claims with a non-missing BILLING-PROV-NPI-NUMSTEP 4: Calculate Luhn check digitOf the claims that meet the criteria from STEP 3, follow the steps below to calculate the Luhn check digit: 1. Ensure that BILLING-PROV-NPI-NUM only contains digits 0-9.2. Ensure that BILLING-PROV-NPI-NUM has length 10.3. Using BILLING-PROV-NPI-NUM, double the digits in slots 1, 3, 5, 7, and 9. 4. If the doubling of the digits results in a number that is greater than or equal to 10, split the digits. For example, 14 becomes 1 and 4. 5. Add the digits from step 4 to the digits in slots 2, 4, 6, and 8.6. Add 24 to the sum from step 5. 7. Round the result from step 6 up to the nearest 10s place.8. Subtract the result from step 6 from the result in step 7.Example: Billing Provider NPI Num = 12345678931. Passes check2. Passes check3. Double odd-slotted digits: 2 6 10 14 18 4. Split digits 10 and over: 2 6 1 0 1 4 1 85. Add digits from above and even-slotted digits: 2 + 6 + 1 + 0 + 1 + 4 + 1 + 8 + 2 + 4 + 6 + 8 = 43. 6. Add 24: 24 + 43 = 67 7. Round up: 67 rounds up to 708. Subtract: 70 - 67 = 3STEP 5: Invalid billing provider NPI numberOf the claims that meet the criteria from STEP 4, keep those that meet the following criteria: 1a. Luhn check digit from STEP 4 does not equal 10th digit of BILLING-PROV-NPI-NUMOR1b. BILLING-PROV-NPI-NUM does not begin with “1”STEP 6: Calculate percentDivide the count from STEP 5 from STEP 3 |
N/A |