MCR-64-001

Key Information

Measure Name	% of crossover claim headers where MEDICARE-PAID-AMT, TOT-MEDICARE-COINS-AMT, and TOT-MEDICARE-DEDUCTIBLE-AMT are 0 or missing
File Type	CIP
Measure ID	MCR-64-001_1-5
Measure Type	Claims Percentage
Content area	MCR

Measure Name

% of crossover claim headers where MEDICARE-PAID-AMT, TOT-MEDICARE-COINS-AMT, and TOT-MEDICARE-DEDUCTIBLE-AMT are 0 or missing

File Type

CIP

Measure ID

MCR-64-001_1-5

Measure Type

Claims Percentage

Content area

MCR

Validation

Validation Type	Inferential

Validation Type

Inferential

Measure Priority

Measure Priority	Medium
Focus Area	Managed care
Category	Expenditures

Medium

Focus Area

Managed care

Category

Expenditures

Claim Information

Claim Type	Medicaid,Enc or CHIP,Enc
Adjustment Type	Non-void
Crossover Type	Crossover

Claim Type

Medicaid,Enc or CHIP,Enc

Adjustment Type

Non-void

Crossover Type

Crossover

Thresholds

Minimum	0
Maximum	0.1
TA Minimun	0
TA Maximum	0.1
Longitudinal Threshold	N/A
For TA (for including in compliance training)	TA- Inferential
For TA (Longitudinal)	No

Minimum

Maximum

0.1

TA Minimun

TA Maximum

0.1

Longitudinal Threshold

N/A

For TA
(for including in compliance training)

TA- Inferential

For TA
(Longitudinal)

Data Elements

DD Data Element	MEDICARE-PAID-AMT • TOT-MEDICARE-COINS-AMT • TOT-MEDICARE-DEDUCTIBLE-AMT
DD Data Element Number	CIP228 • CIP117 • CIP116

DD Data Element

MEDICARE-PAID-AMT • TOT-MEDICARE-COINS-AMT • TOT-MEDICARE-DEDUCTIBLE-AMT

DD Data Element Number

CIP228 • CIP117 • CIP116

Annotation	Calculate the percentage of Medicaid and S-CHIP encounter: non-void, crossover, paid IP claims where Medicare paid amount, total Medicare coinsurance amount, and total Medicare deductible amount are equal to 0 or are missing
Specification	STEP 1: Active non-duplicate paid IP claims during report month Define the IP claims universe at the header level that satisfy the following criteria: 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. STEP 2: Medicaid and S-CHIP Encounter: Non-void, Crossover, 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. CROSSOVER-IND = "1" 3. ADJUSTMENT-IND not equal to "1" 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: No Medicare Amounts Of the claims that meet the criteria from STEP 3, further restrict them by the following criteria: 1. MEDICARE-PAID-AMT = 0 or is missing 2. TOT-MEDICARE-COINS-AMT = 0 or is missing 3. TOT-MEDICARE-DEDUCTIBLE-AMT = 0 or is missing STEP 5: Calculate percentage Divide the count of claim headers from STEP 4 by the count of claim headers from STEP 3.

Annotation

Calculate the percentage of Medicaid and S-CHIP encounter: non-void, crossover, paid IP claims where Medicare paid amount, total Medicare coinsurance amount, and total Medicare deductible amount are equal to 0 or are missing

Specification

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

Define the IP claims universe at the header level that satisfy the following criteria:

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.

STEP 2: Medicaid and S-CHIP Encounter: Non-void, Crossover, 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. CROSSOVER-IND = "1"

3. ADJUSTMENT-IND not equal to "1"

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: No Medicare Amounts

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

1. MEDICARE-PAID-AMT = 0 or is missing

2. TOT-MEDICARE-COINS-AMT = 0 or is missing

3. TOT-MEDICARE-DEDUCTIBLE-AMT = 0 or is missing

STEP 5: Calculate percentage

Divide the count of claim headers from STEP 4 by the count of claim headers from STEP 3.

Published Date	Data Guide Version	DQM	Action	Field	Before	After
06/02/2023	3.8.0	MCR-64-001_1-5	UPDATE	Priority	High	Medium
04/21/2023	3.6.0	MCR-64-001_1-5	UPDATE	Specification	STEP 1: Active non-duplicate paid IP claims during report monthDefine the IP 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 and S-CHIP Encounter: Non-void, Crossover, 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. CROSSOVER-IND = "1"3. ADJUSTMENT-IND not equal to "1" STEP 3: No Medicare AmountsOf the claims that meet the criteria from STEP 2, further restrict them by the following criteria: 1. MEDICARE-PAID-AMT = 0 or is missing2. TOT-MEDICARE-COINS-AMT = 0 or is missing3. TOT-MEDICARE-DEDUCTIBLE-AMT = 0 or is missingSTEP 4: Calculate percentageDivide the count of claim headers from STEP 3 by the count of claim headers from STEP 2	STEP 1: Active non-duplicate paid IP claims during report monthDefine the IP 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 and S-CHIP Encounter: Non-void, Crossover, 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. CROSSOVER-IND = "1"3. ADJUSTMENT-IND not equal to "1" 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: No Medicare AmountsOf the claims that meet the criteria from STEP 3, further restrict them by the following criteria: 1. MEDICARE-PAID-AMT = 0 or is missing2. TOT-MEDICARE-COINS-AMT = 0 or is missing3. TOT-MEDICARE-DEDUCTIBLE-AMT = 0 or is missingSTEP 5: Calculate percentageDivide the count of claim headers from STEP 4 by the count of claim headers from STEP 3.