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Measure Name | % of claim headers that are original |
---|---|
File Type | CLT |
Measure ID | MCR-S-014-5 |
Measure Type | Claims Percentage |
Content area | MCR |
Validation Type | Inferential |
---|
Measure Priority | Medium |
---|---|
Focus Area | Managed care |
Category | Expenditures |
Claim Type | Medicaid,Enc |
---|---|
Adjustment Type | All Adjustment Types |
Crossover Type | All Indicators |
Minimum | 0.26 |
---|---|
Maximum | 0.9999 |
TA Minimun | 0.26 |
TA Maximum | 0.9999 |
Longitudinal Threshold | N/A |
For TA
(for including in compliance training) |
TA- Inferential |
For TA
(Longitudinal) |
No |
DD Data Element | ADJUSTMENT-IND |
---|---|
DD Data Element Number | CLT025 |
Annotation | Percentage of Medicaid Encounter: original and adjustment, paid LT claims that are original |
---|---|
Specification |
STEP 1: Active non-duplicate LT claims during DQ report month Define the LT claims universe at the header level that satisfy the following criteria: 1. Reporting Period for 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 Encounter: Original and Adjustment, Paid Claims Of the claims that meet the criteria from STEP 1, further restrict them by the following criteria: 1. TYPE-OF-CLAIM = "3" STEP 3: Original claims Of the claims that meet the criteria from STEP 2, select records where 1. ADJUSTMENT-IND = "0" STEP 4: Calculate the percentage for the measure Divide the count of claims from STEP 3 by the count of claims from STEP 2 |