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TMSIS Dataguide Medicaid.gov
Version 3.28.0

MCR-9-006_2-19

Data Quality Measure
Last updated

No Updates

Key Information

Measure Name % of PCCM capitated payments with a non-missing plan ID where plan ID number equals the Billing Provider Number or Billing Provider NPI Number
File Type COT
Measure ID MCR-9-006_2-19
Measure Type Claims percentage
Content area MCR

Validation

Validation Type Inferential

Measure Priority

Measure Priority Medium
Focus Area Managed care
Category Provider information

Claim Information

Claim Type Medicaid,Cap
Adjustment Type Original
Crossover Type All Indicators

Thresholds

Minimum 0
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

Data Elements

DD Data Element TYPE-OF-SERVICE • PLAN-ID-NUMBER • BILLING-PROV-NUM • BILLING-PROV-NPI-NUM
DD Data Element Number COT186 • COT066 • COT112 • COT113

Annotation Calculate the percentage of PCCM capitated payments with a non-missing Plan Id where Plan Id Number equals the Billing Provider Number or Billing Provider NPI Number
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: Plan id match

Of the claim lines that meet the criteria from STEP 4, further restrict them by the following criteria:

1a. PLAN-ID-NUMBER = BILLING-PROV-NUM

OR

1b. PLAN-ID-NUMBER = BILLING-PROV-NPI-NUM



STEP 6: Calculate the percentage for the measure

Divide the count of claim lines from STEP 5 by the count of claim lines from STEP 4