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Measure Name | % of PCCM (TYPE-OF-SERVICE) capitation payments with a non-missing plan ID that do not have a corresponding managed care participation PCCM plan |
---|---|
File Type | Multiple Files |
Measure ID | MCR-9-006_1-18 |
Measure Type | Claims percentage |
Content area | MCR |
Validation Type | Inferential |
---|
Measure Priority | Medium |
---|---|
Focus Area | Managed care |
Category | Expenditures |
Claim Type | Medicaid,Cap |
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Adjustment Type | Original |
Crossover Type | All Indicators |
Minimum | 0 |
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Maximum | 0.05 |
TA Minimun | 0 |
TA Maximum | 0.05 |
Longitudinal Threshold | N/A |
For TA
(for including in compliance training) |
TA- Inferential |
For TA
(Longitudinal) |
No |
DD Data Element | TYPE-OF-SERVICE • PLAN-ID-NUMBER • MANAGED-CARE-PLAN-ID • MSIS-IDENTIFICATION-NUM • MSIS-IDENTIFICATION-NUM • MANAGED-CARE-PLAN-TYPE |
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DD Data Element Number | COT186 • COT066 • ELG192 • COT022 • ELG191 • ELG193 |
Annotation | Calculate the percentage of PCCM capitation payments with a non-missing plan id that do not have a corresponding managed care participation PCCM plan |
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Specification |
STEP 1: Active non-duplicate paid OT claims during report month Define the OT claims universe at the line level by importing both headers and lines that satisfy the following criteria: For Headers: 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. For Lines: 1. Reporting Period from the filename = DQ report month 2. CLAIM-LINE-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing 3. No Line Duplicates: Duplicates are dropped at the line level if the following data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, LINE-NUM-ORIG, LINE-NUM-ADJ, and LINE-ADJSTMT-IND. 4. Lines merge to a header using ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND=LINE-ADJSTMT-IND. STEP 2: Medicaid Capitation Payment: Original, Paid Claims Of the claims that meet the criteria from STEP 1, further restrict them by the following criteria: 1. TYPE-OF-CLAIM = "2" 2. ADJUSTMENT-IND = "0" STEP 3: Type of service Of the claims that meet the criteria from STEP 2, further restrict them by the following criteria: 1. TYPE-OF-SERVICE = "120" STEP 4: Non-missing plan id Of the claims that meet the criteria from STEP 3, further restrict them by the following criteria: 1. PLAN-ID-NUMBER is not missing STEP 5: 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 6: Managed care enrollment on the last day of DQ report month Of the MSIS-IDs that meet the criteria from STEP 5, 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 7: No managed care participation PCCM plan Of the claim lines that meet the criteria from STEP 4, further restrict them by attempting to merge them with the data from STEP 6 and keeping those that satisfy the following criteria: 1a. PLAN-ID-NUMBER = MANAGED-CARE-PLAN-ID 2a. MSIS-IDENTIFICATION-NUM matches 3a. MANAGED-CARE-PLAN-TYPE does NOT equal "02" or "03" for any records where 1a and 2a are satisfied OR It is not the case that: 1b. PLAN-ID-NUMBER = MANAGED-CARE-PLAN-ID 2b. MSIS-IDENTIFICATION-NUM matches STEP 8: Calculate the percentage for the measure Divide the count of claims from STEP 7 by the count of claims from STEP 4 |