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Measure Name | % of Health/Medical Home (MANAGED-CARE-PLAN-TYPE = 70) enrollees with no capitation payments for Health/Medical Home |
---|---|
File Type | Multiple Files |
Measure ID | MCR-65-011-11 |
Measure Type | Non-Claims Percentage |
Content area | ELG MCR MULTI |
Validation Type | Inferential |
---|
Measure Priority | High |
---|---|
Focus Area | Managed care |
Category | Program participation |
Claim Type | N/A |
---|---|
Adjustment Type | N/A |
Crossover Type | N/A |
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 | MSIS-IDENTIFICATION-NUM • MSIS-IDENTIFICATION-NUM • MANAGED-CARE-PLAN-TYPE • PLAN-ID-NUMBER • MANAGED-CARE-PLAN-ID • TYPE-OF-CLAIM |
---|---|
DD Data Element Number | ELG191 • COT022 • ELG193 • COT066 • ELG192 • COT037 |
Annotation | Calculate the percentage of eligibles enrolled in a Health/Medical Home that do not have Medicaid Capitation Payment: Paid OT claims with the corresponding managed care plan type |
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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 participation 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: Enrollment in Health/Medical Home Of the MSIS IDs that meet the criteria for STEP 2, further refine the population to MSIS IDs where MANAGED-CARE-PLAN-TYPE = ("70") STEP 4: Active non-duplicate paid OT claims during report month Define the OT 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 5: Medicaid & S-CHIP Capitation Payment: Original and Adjustment, Paid Claims Of the claims that meet the criteria from STEP 4, further restrict them by the following criteria: 1. TYPE-OF-CLAIM = "B" or "2" STEP 6: Link MSIS IDs from EL to OT Retain the MSIS IDs from STEP 3 that link to an OT claim from STEP 5 using the Plan IDs STEP 7: Count MSIS IDs without Health/Medical Home Subtract the number of unique MSIS IDs in STEP 6 from the number of unique MSIS IDs in STEP 3 STEP 8: Calculate percentage Divide the count of unique MSIS IDs in STEP 7 by the count of unique MSIS IDs in STEP 3 |