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TMSIS Dataguide Medicaid.gov
Version 3.27.0

MCR-65-012-12

Data Quality Measure
Last updated

Key Information

Measure Name % of Integrated Care for Dual Eligibles (MANAGED-CARE-PLAN-TYPE = 80) enrollees with no capitation payments for Integrated Care for Dual Eligibles
File Type Multiple Files
Measure ID MCR-65-012-12
Measure Type Non-Claims Percentage
Content area ELG MCR MULTI

Validation

Validation Type Inferential

Measure Priority

Measure Priority High
Focus Area Managed care
Category Program participation

Claim Information

Claim Type N/A
Adjustment Type N/A
Crossover Type N/A

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

Data Elements

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 Integrated Care for Dual Eligibles that do not have Medicaid Capitation Payment: Paid OT claims with the corresponding managed care plan type
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 Integrated Care for Dual Eligibles

Of the MSIS IDs that meet the criteria for STEP 2, further refine the population to MSIS IDs where MANAGED-CARE-PLAN-TYPE = ("80")



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 Integrated Care for Dual Eligibles

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