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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 | CLT |
Measure ID | MCR-64-002_1-6 |
Measure Type | Claims Percentage |
Content area | MCR |
Validation Type | Inferential |
---|
Measure Priority | Medium |
---|---|
Focus Area | Managed care |
Category | Expenditures |
Claim Type | Medicaid,Enc or CHIP,Enc |
---|---|
Adjustment Type | Non-void |
Crossover Type | Crossover |
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 |
DD Data Element | MEDICARE-PAID-AMT • TOT-MEDICARE-COINS-AMT • TOT-MEDICARE-DEDUCTIBLE-AMT |
---|---|
DD Data Element Number | CLT179 • CLT068 • CLT067 |
Annotation | Calculate the percentage of Medicaid and S-CHIP encounter: non-void, crossover, paid LT 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 LT claims during report month Define the LT 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. |