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TMSIS Dataguide Medicaid.gov
Version 3.28.0

PRV-6-001-1

Data Quality Measure
Last updated

Key Information

Measure Name % of Submitting State Provider IDs with FACILITY-GROUP-INDIVIDUAL-CODE = 01, 02 (facility or group) that do not have a Provider Classification Code that indicates a facility or group
File Type PRV
Measure ID PRV-6-001-1
Measure Type Non-claims percentage
Content area PRO

Validation

Validation Type Inferential

Measure Priority

Measure Priority Medium
Focus Area N/A
Category Provider identifiers

Claim Information

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

Thresholds

Minimum 0
Maximum 0.2
TA Minimun 0
TA Maximum 0.2
Longitudinal Threshold N/A
For TA
(for including in compliance training) 		TA- Inferential
For TA
(Longitudinal) 		No

Data Elements

DD Data Element SUBMITTING-STATE-PROV-ID • FACILITY-GROUP-INDIVIDUAL-CODE • PROV-CLASSIFICATION-TYPE • PROV-CLASSIFICATION-CODE
DD Data Element Number PRV019 • PRV026 • PRV088 • PRV089

Annotation Calculate the percentage of submitting state provider IDs that have a facility group individual code indicating facility or group but whose provider classification code does not indicate facility or group
Specification STEP 1: Provider enrolled on the last day of DQ report month

Define the provider population from segment PROV-MEDICAID-ENROLLMENT-PRV00007 by keeping active records that satisfy the following criteria:

1. PROV-MEDICAID-EFF-DATE <= last day of the reporting month

2. PROV-MEDICAID-END-DATE >= last day of the reporting month OR missing

3. SUBMITTING-STATE-PROV-ID is not missing



STEP 2: Provider attributes are active on last day of DQ report month

Of the providers that meet the criteria from STEP 1, further refine the population using segment PROVIDER-ATTRIBUTES-MAIN- PRV00002 by keeping records that satisfy the following criteria:

1. PROV-ATTRIBUTES-EFF-DATE <= last day of the reporting month

2. PROV-ATTRIBUTES-END-DATE >= last day of the reporting month or missing

3. SUBMITTING-STATE-PROV-ID is not missing



STEP 3: Provider is a facility or group

Of the SUBMITTING-STATE-PROV-IDs that meet the criteria from STEP 2, further refine the population by keeping records that satisfy the following criteria:

1. FACILITY-GROUP-INDIVIDUAL-CODE = "01" or "02"



STEP 4: Provider taxonomy is active on the last day of DQ report month

Of the providers that meet the criteria from STEP 3, further refine the population using segment PROVIDER-TAXONOMY-CLASSIFICATION-PRV00006 by keeping records that satisfy the following criteria:

1a. PROV-TAXONOMY-CLASSIFICATION-EFF-DATE <= last day of the reporting month

2a. PROV-TAXONOMY-CLASSIFICATION-END-DATE >= last day of the reporting month OR missing

OR

1b. PROV-TAXONOMY-CLASSIFICATION-EFF-DATE is missing

2b. PROV-TAXONOMY-CLASSIFICATION-END-DATE is missing



STEP 5: Provider Classification Lookup Designation is "Individual" or missing

Of the SUBMITTING-STATE-PROV-IDs that meet the criteria from STEP 4, further refine the population by keeping records that meet the following criteria:



1a. PROV-IDENTIFIER-TYPE and PROVIDER-CLASSIFICATION-CODE match values in Provider Classification lookup table

AND

1b. Provider Classification Lookup Designation is never “Non-Individual”

OR

2. PROV-IDENTIFIER-TYPE and PROVIDER-CLASSIFICATION-CODE are never equal to values in Provider Classification lookup table

OR

3. PROV-IDENTIFIER-TYPE is always missing

OR

4. PROVIDER-CLASSIFICATION-CODE is always missing



STEP 6: Calculate percentage

Divide the count of unique SUBMITTING-STATE-PROVIDER-IDENTIFIER values from STEP 5 by the count of unique SUBMITTING-STATE-PROVIDER-IDENTIFIER values from STEP 3