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{"measureId": 105, "measureName": "Billing Provider Type, Specialty, and Taxonomy - OT Institutional", "groupId": 6, "groupName": "Provider Information", "pdfVersionLink": "downloads/background-and-methods/TAF-DQ-Bill-Prov-Type-OT-Inst.pdf", "background": {"content": "<p class=\"msword-paragraph\"> Users of the T-MSIS Analytic Files (TAF) may want to identify the providers or categories of providers that deliver services to Medicaid and Children&rsquo;s Health Insurance Program (CHIP) beneficiaries. A claim in the TAF could include information for up to six providers, depending on the file type. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-2\" id=\"footnote-ref-2\">[1]</a> </sup> </sup> A provider could be a facility, a group of individual practitioners, or an individual practitioner. The provider types most often used for claims-based analyses include the billing, servicing, prescribing, and dispensing providers.</p><p class=\"msword-paragraph\"> The billing provider represents the entity that submits the claim and is reimbursed by the Medicaid or CHIP agency. Information about the billing provider is available in all TAF claims files: inpatient (IP), long-term care (LT), other services (OT), and pharmacy (RX).</p><p class=\"msword-paragraph\"> The servicing provider, in contrast, represents the individual practitioner who was responsible for or provided direct care to the beneficiary (that is, the rendering provider). Information about servicing provider is available in the IP, LT, and OT files. In some cases, the servicing provider is the same as the billing provider. In other cases, the servicing and billing provider differ, such as when a hospital or large group practice bills for services but an individual physician employed by the hospital or group provides the direct care and is the serving provider. Because institutional claims in the IP and LT files represent facility costs and are often submitted by the hospitals and skilled nursing facilities where the care occurred, analyses using these claims would typically only use the billing provider information.</p><p class=\"msword-paragraph\"> For prescription drug claims, the billing provider is the pharmacy where the prescription was filled, the prescribing provider is the individual practitioner who prescribed a prescription drug to a beneficiary, and the dispensing provider is the pharmacist who filled the prescription or was responsible for overseeing the filling of the prescription. Because the billing provider represents the entity that submits a claim and is reimbursed by the Medicaid or CHIP agency, analyses using prescription drug claims typically focus on the billing provider information.</p><p class=\"msword-paragraph\"> Data elements related to the billing provider can offer insight into the characteristics of providers who receive payment for Medicaid- and CHIP-funded services. Likewise, data elements related to the servicing provider can offer insight into the characteristics of the individual practitioner who was responsible for or provided direct care to a Medicaid or CHIP beneficiary. There are multiple systems available in TAF claim records for classifying providers, including the following:</p><ul> <li class=\"msword-list-bullet\"> <strong> Provider taxonomy </strong> , which has detailed categories covering all facility, group, and individual provider types. All taxonomy codes must correspond to values from the National Uniform Claim Committee (NUCC) Health Care Provider Taxonomy code set. The billing and servicing provider information on TAF claim records include both the state-reported taxonomy and National Plan and Provider Enumeration System (NPPES) primary taxonomy. The state-reported taxonomy is reported by the provider on the claim form. The NPPES primary taxonomy is pulled from the NPPES data, which represents the information reported by the provider when applying for or updating their National Provider Identifier (NPI). </li> <li class=\"msword-list-bullet\"> <strong> Provider specialty </strong> , which has a limited number of categories for facility and non-physician providers but detailed categories for the physician specialty most relevant to individual physicians or group practices. This information is reported by the state in T-MSIS and is not pulled directly from the claim form. </li> <li class=\"msword-list-bullet\"> <strong> Provider type </strong> , which covers facility, physician, and non-physician providers who commonly participate in Medicaid. This information is reported by the state in T-MSIS and is not pulled directly from the claim form. </li></ul><p class=\"msword-paragraph\"> Each of these classification systems may be best suited to different types of analyses. Although states are encouraged to populate all these fields on all claims, only one classification type is required. In practice, some states only submit information related to some of the classification systems, which may require TAF users to adjust their methodology across states. If the preferred data element has high rates of missingness, TAF users may be able to link the claims record to the provider&rsquo;s record in the Annual Provider File (APR) to obtain the needed information. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-3\" id=\"footnote-ref-3\">[2]</a> </sup> </sup></p><p class=\"msword-paragraph\"> This data quality assessment examines whether any information on billing or servicing provider characteristics is available in claims records, and which type (taxonomy, specialty, or provider type). This information can help users design their analysis by selecting the fields populated in each state or identify states for which it may be necessary to link to the APR to obtain complete information about providers, rather than rely on claims alone.</p><p class=\"msword-paragraph\"></p><ol> <li class=\"footnoteBody\" id=\"footnote-2\" value=\"1\"> <p class=\"msword-footnote-text\"> The inpatient file includes information about billing, referring, servicing, admitting, and operating providers. The long-term care file includes information about billing, referring, servicing, and admitting providers. The other services file includes information about billing, referring, servicing, health home, directing, and supervising providers. The pharmacy claims file includes information about billing, dispensing, and prescribing providers. </p> <p> <a href=\"#footnote-ref-2\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-3\" value=\"2\"> <p class=\"msword-footnote-text\"> States are required to submit information about all providers eligible to provide Medicaid- and CHIP-funded services; these records are captured in the APR. It is possible that missing information in the claim about provider taxonomy, specialty, or type could be imputed by linking to the provider&rsquo;s record in the APR and obtaining the information from that file. In addition, the APR includes information on how states classify providers by &ldquo;authorized category of service,&rdquo; a classification scheme that can be used to identify certain non-medical provider categories not captured in the other classification systems, such as transportation or personal care service providers. For more information on the completeness of these fields in each state&rsquo;s APR file, see the DQ Atlas single-topic displays for <a aria-label=\"View DQ Atlas single topic display for Group and Individual Providers - Classification Types\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g6m95\">Group and Individual Providers - Classification Types</a> and <a aria-label=\"View DQ Atlas single topic display for Facilities - Classification Types\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g6m97\">Facilities - Classification Types</a> . </p> <p> <a href=\"#footnote-ref-3\">&uarr;</a> </p> </li></ol>", "footnotes": [{"number": 2, "content": "<li class=\"footnoteBody\" id=\"footnote-2\" value=\"1\"><p class=\"msword-footnote-text\"> The inpatient file includes information about billing, referring, servicing, admitting, and operating providers. The long-term care file includes information about billing, referring, servicing, and admitting providers. The other services file includes information about billing, referring, servicing, health home, directing, and supervising providers. The pharmacy claims file includes information about billing, dispensing, and prescribing providers. </p><p><a href=\"#footnote-ref-2\">\u2191</a></p></li>"}, {"number": 3, "content": "<li class=\"footnoteBody\" id=\"footnote-3\" value=\"2\"><p class=\"msword-footnote-text\"> States are required to submit information about all providers eligible to provide Medicaid- and CHIP-funded services; these records are captured in the APR. It is possible that missing information in the claim about provider taxonomy, specialty, or type could be imputed by linking to the provider\u2019s record in the APR and obtaining the information from that file. In addition, the APR includes information on how states classify providers by \u201cauthorized category of service,\u201d a classification scheme that can be used to identify certain non-medical provider categories not captured in the other classification systems, such as transportation or personal care service providers. For more information on the completeness of these fields in each state\u2019s APR file, see the DQ Atlas single-topic displays for <a aria-label=\"View DQ Atlas single topic display for Group and Individual Providers - Classification Types\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g6m95\">Group and Individual Providers - Classification Types</a> and <a aria-label=\"View DQ Atlas single topic display for Facilities - Classification Types\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g6m97\">Facilities - Classification Types</a> . </p><p><a href=\"#footnote-ref-3\">\u2191</a></p></li>"}]}, "methods": {"content": "<p class=\"msword-callout\"> The following describes current methods used to assess data quality. Information about methods previously used to assess data quality can be found at the bottom of this section.</p><p class=\"msword-paragraph\"> We examined the values for provider type, specialty, and taxonomy codes for the providers most examined in analyses for the TAF IP, LT, OT, and RX files (Table 1). <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-2\" id=\"footnote-ref-2\">[3]</a> </sup> </sup> We included both fee-for-service (FFS) claims and managed care encounter records, which represent claims paid by managed care organizations and should generally follow the same reporting standards for billing and servicing providers. We excluded financial transaction records, supplemental payments, and &ldquo;other&rdquo; records that the state did not classify as being covered by either the Medicaid or CHIP programs. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-3\" id=\"footnote-ref-3\">[4]</a> </sup> </sup> <sup> &nbsp; </sup> We also excluded states from the analysis of each file if the number of header records in the TAF was low enough to be unusable. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-4\" id=\"footnote-ref-4\">[5]</a> </sup> </sup> <sup> &nbsp; </sup> For Illinois, we restricted our analysis to the original version of the claim and excluded all subsequent adjustment records in the state&rsquo;s TAF data. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-5\" id=\"footnote-ref-5\">[6]</a> </sup> </sup></p><p class=\"msword-table-title\"> Table 1. Crosswalk between file type, data element description, and TAF variable name</p><table aria-label=\"Table 1. Crosswalk between file type, data element description, and TAF variable name\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> File type </p> </th> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Data element description </p> </th> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Variable name </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> IP, LT, OT </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Billing provider </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> BLG_PRVDR_TYPE_CD </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> IP, LT, OT, RX </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Billing provider specialty code </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> BLG_PRVDR_SPCLTY_CD </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> IP, LT, OT, RX </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Billing provider state-reported taxonomy code </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> BLG_PRVDR_TXNMY_CD </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> IP, LT, OT </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Billing provider NPPES primary taxonomy code </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> BLG_PRVDR_NPPES_TXNMY_CD </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> OT </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Servicing provider type code </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> SRVCNG_PRVDR_TYPE_CD </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> OT </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Servicing provider specialty code </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> SRVCNG_PRVDR_SPCLTY_CD </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> OT </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Servicing provider state-reported taxonomy code </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> SRVCNG_PRVDR_TXNMY_CD </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> OT </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Servicing provider NPPES primary taxonomy code </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> SRVCNG_PRVDR_NPPES_TXNMY_CD </p> </td> </tr> </tbody></table><p class=\"msword-paragraph\"> The provider type code includes 57 different valid values, covering both facilities and professionals. As shown in Table 2, we grouped these values into those that are expected, unexpected, and unusable for billing providers for each of the three file types in which this data element is present (IP, LT, OT) and for servicing providers in the OT file.</p><p class=\"msword-paragraph\"> In the IP file, we would expect to see only general hospitals and Indian Health Service facilities as billing providers. In the LT file, we would expect to see nursing facilities, intermediate care facilities for individuals with intellectual or developmental disabilities, and psychiatric facilities as billing providers, as well as general hospitals in selected cases. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-6\" id=\"footnote-ref-6\">[7]</a> </sup> </sup> <sup class=\"msword-footnote-reference\"> &nbsp; </sup> In the OT file, we would expect to see a broad range of both facilities and professionals billing for and directly providing services.</p><p class=\"msword-paragraph\"> For all three files, we examined the &ldquo;all other&rdquo; code separately from the expected and unexpected categories. In some instances, use of the non-specific &ldquo;all other&rdquo; code may reflect the possibility that the provider is not represented in the list of valid provider type codes, which is the case for certain types of home- and community-based services (HCBS) and non-emergency medical transport providers. Although this code is valid and not considered an unexpected value in any file, it does not provide any information about the billing or servicing provider and thus renders the data element unusable for analysis.</p><p class=\"msword-table-title\"> Table 2. Classification of provider type codes, by file and provider field</p><table aria-label=\"Table 2. Classification of provider type codes, by file and provider field\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> File and provider field </p> </th> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Expected codes </p> </th> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Unusable codes (&ldquo;all other&rdquo; value) </p> </th> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Unexpected codes </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> IP&mdash;billing provider </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 42, 51 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 57 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> All other values </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> LT&mdash;billing provider </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 42, 43, 44, 45 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 57 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> All other values </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> OT&mdash;billing and servicing provider </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 01&minus;56 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 57 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> None </p> </td> </tr> </tbody></table><p class=\"msword-table-source\"> Source: A full list of values is available in the TAF Claims Codebook at&nbsp; <a aria-label=\"View the TAF Claims Codebook on the Chronic Conditions Data Warehouse Data Dictionaries page\" href=\"https://www2.ccwdata.org/web/guest/data-dictionaries\">https://www2.ccwdata.org/web/guest/data-dictionaries</a> . The provider type code values are identical across all three files.</p><p class=\"msword-paragraph\"> The provider specialty code includes 115 different valid values, covering both facilities and professionals. As shown in Table 3, we grouped these values into those that are expected and unexpected for each of the file types and provider fields. In the IP file, we would expect to see only general hospitals as billing providers. In the LT file, we would expect to see nursing facilities, intermediate care facilities for individuals with intellectual or developmental disabilities, and psychiatric facilities as billing providers, as well as general hospitals in selected cases. <sup> &nbsp; </sup> In the OT file, we would expect to see a broad range of both facilities and professionals billing for and directly providing services. In the RX file, we would expect to see pharmacies, medical supply companies, department stores, and grocery stores as billing providers. For all files and provider fields, we examined the &ldquo;all other&rdquo; codes (billing provider specialty code 87&mdash;All Other Suppliers) separately from the expected and unexpected categories. Although this code is valid and not considered an unexpected value in any file, it does not provide any information about the provider and thus renders the data element unusable for analysis.</p><p class=\"msword-table-title\"> Table 3. Classification of provider specialty codes, by file and provider field</p><table aria-label=\"Table 3. Classification of provider specialty codes, by file and provider field\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> File and provider field </p> </th> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Expected codes </p> </th> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Unusable codes (&ldquo;all other&rdquo; value) </p> </th> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Unexpected codes </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> IP&mdash;billing provider </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> A0 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 87 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> All other values except 88 and 99, which are treated as missing </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> LT&mdash;billing provider </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> A0, A1, A2, A3, B4 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 87 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> All other values except 88 and 99, which are treated as missing </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> OT&mdash;billing and servicing provider </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 1&minus;86, 89&minus;98, A0&minus;B5 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 87 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> All other values except 88 and 99, which are treated as missing </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> RX&mdash;billing provider </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 51&ndash;54, 58, 73, A5, A6, A9, B1, B3, B4 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 87 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> All other values except 88 and 99, which are treated as missing </p> </td> </tr> </tbody></table><p class=\"msword-table-source\"> Source: A full list of values is available in the TAF Claims Codebook at&nbsp; <a aria-label=\"View the TAF Claims Codebook on the Chronic Conditions Data Warehouse Data Dictionaries page\" href=\"https://www2.ccwdata.org/web/guest/data-dictionaries\">https://www2.ccwdata.org/web/guest/data-dictionaries</a> . The provider specialty code values are identical across all claims files.</p><p class=\"msword-paragraph\"> The state-reported billing provider taxonomy code is a 10-character alphanumeric code that identifies the provider&rsquo;s area of specialization. As shown in Table 4, we grouped these values into those that are expected and unexpected for each of the file types. In the IP file, we would expect to see inpatient hospitals as billing providers. In the LT files we would expect to see nursing facilities, intermediate care facility services for individuals with intellectual disabilities, mental health facility services, and independent (free-standing) psychiatric wings of acute care hospitals as billing providers. In the OT file, we would expect to see a broad range of both facilities and professionals billing for and directly providing services. In the RX file, we would expect to see pharmacies and other suppliers as billing providers.</p><p class=\"msword-paragraph\"> In addition to the state-reported provider taxonomy codes, IP, OT and LT files produced in 2022 and later years also include a constructed taxonomy variable for billing and servicing providers, the NPPES primary taxonomy code (*_NPPES_TXNMY_CD), that represents the provider&rsquo;s primary taxonomy information as reported in the National Plan and Provider Enumeration System (NPPES) based on the provider&rsquo;s National Provider Identifier. We used the same criteria as the state-reported taxonomy codes to determine expected and unexpected values for each file type.</p><p class=\"msword-table-title\"> Table 4. Classification of provider taxonomy codes, by file and provider field</p><table aria-label=\"Table 4. Classification of provider taxonomy codes, by file and provider field\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> File and provider field </p> </th> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Expected codes </p> </th> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Unexpected codes </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> IP&mdash;billing provider </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> First 2 digits of taxonomy code are 27 or 28 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> All other values </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> LT&mdash;billing provider </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Taxonomy code begins with 283Q, 283X, 282E, 31, 32, 385H, or 281P </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> All other values </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> OT&mdash;billing and servicing provider </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> All valid taxonomy codes </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> None </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> RX&mdash;billing provider </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> First 2 digits of taxonomy code are 33, first 3 digits are 183, or 302R00000X <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-7\" id=\"footnote-ref-7\">[8]</a> </sup> </sup> </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> All other values </p> </td> </tr> </tbody></table><p class=\"msword-table-source\"> Source: The health care provider taxonomy code set can be found at <a aria-label=\"View the 2019 Health Care Provider Taxonomy Code Set\" href=\"http://www.wpc-edi.com/reference/codelists/healthcare/health-care-provider-taxonomy-code-set/\">http://www.wpc-edi.com/reference/codelists/healthcare/health-care-provider-taxonomy-code-set/</a> . The provider taxonomy code values are identical across all claims files.</p><p class=\"msword-paragraph\"> We grouped states into categories of low, medium, and high concern about the usability of their data, based on the percentage of header records (or for servicing providers in the OT file, claim lines) that had an expected provider type, specialty, state-reported taxonomy code, or NPPES primary taxonomy code for the file and provider fields (Table 5).</p><p class=\"msword-paragraph\"> Because users of the OT file may be interested in professional or institutional (facility) claims, we conducted the DQ assessment separately for each of these claim types. Table 6 shows the methodology used to classify each claim header as a professional or institutional claim. Any claim that did not meet at least one of the criteria for a professional or institutional claim was considered unclassified and is not included in this analysis. Note that the servicing provider analyses were conducted at the claim line level, but the claims were classified as professional or institutional claims at the claim header level.</p><p class=\"msword-table-title\"> Table 5. Criteria for DQ assessment of provider type, specialty, and taxonomy code</p><table aria-label=\"Table 5. Criteria for DQ assessment of provider type, specialty, and taxonomy code\" class=\"dq-assessment-table\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Percentage of records with an expected provider type, specialty, state-reported taxonomy code, or NPPES primary taxonomy code </p> </th> <th class=\"msword-table-header-left dq-assessment-col\"> <p class=\"msword-table-header-left\"> DQ assessment </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &ge; 90 percent </p> </td> <td class=\"msword-table-text-left dq-assessment-col dq-level low\"> <p class=\"msword-table-text-left\"> Low concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 80 percent &le; x &lt; 90 percent </p> </td> <td class=\"msword-table-text-left dq-assessment-col dq-level medium\"> <p class=\"msword-table-text-left\"> Medium concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 50 percent &le; x &lt; 80 percent </p> </td> <td class=\"msword-table-text-left dq-assessment-col dq-level high\"> <p class=\"msword-table-text-left\"> High concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &lt; 50 percent </p> </td> <td class=\"msword-table-text-left dq-assessment-col dq-level unusable\"> <p class=\"msword-table-text-left\"> Unusable </p> </td> </tr> </tbody></table><p class=\"msword-table-title\"> Table 6. Classification of OT claim headers as professional or facility claims</p><table aria-label=\"Table 6. Classification of OT claim headers as professional or facility claims\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Claim category </p> </th> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Identification rules </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Professional </p> </td> <td> <p class=\"msword-table-text-left\"> The record must meet at least one of the following criteria: </p> <ul> <li class=\"msword-table-list-bullet\"> Has a valid place of service code on the header record and a missing or invalid revenue code on all line records </li> <li class=\"msword-table-list-bullet\"> Has a missing or invalid place of service code in the header record, a missing or invalid type of bill code in the header record, and a missing or invalid revenue code plus a valid procedure code in all line records </li> </ul> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Institutional </p> </td> <td> <p class=\"msword-table-text-left\"> The record must meet at least one of the following criteria: </p> <ul> <li class=\"msword-table-list-bullet\"> Has at least one line with a valid revenue code </li> <li class=\"msword-table-list-bullet\"> Has a valid type of bill code and a missing or invalid place of service code </li> </ul> </td> </tr> </tbody></table><p class=\"msword-header\"> Methods previously used to assess data quality</p><p> <a id=\"_Hlk71024897\"></a> Table 7 includes information about methods previously used to assess data quality and the data years and versions assessed using those methods. Each table record describes how the assessment methods for the listed data years and versions differ from current methods. Aside from those differences, the assessments for these data years and versions align with current methods. All data years and versions not listed in the table are assessed using current methods.</p><p class=\"msword-table-title\"> Table 7. Previously used methods and applicable data years and versions</p><table aria-label=\"Table 7. Previously used methods and applicable data years and versions\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Data year(s) and version(s) </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Description of difference(s) from current methods </p> </th> </tr> </thead> <tbody> <tr> <td> <ul> <li class=\"msword-table-list-bullet\"> 2014 Release 2 </li> <li class=\"msword-table-list-bullet\"> 2015 Release 2 </li> <li class=\"msword-table-list-bullet\"> 2016 Releases 1 and 2 </li> <li class=\"msword-table-list-bullet\"> 2017 Releases 1 and 2 </li> <li class=\"msword-table-list-bullet\"> 2018 Releases 1 and 2 </li> <li class=\"msword-table-list-bullet\"> 2019 Preliminary Release and Release 1 </li> </ul> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> The assessments of billing provider information for the IP, LT, and OT file are only based on the percentage of claims with an expected billing provider type code. Measures related to billing provider taxonomy code and billing provider specialty code are not calculated or included in the assessments. </li> <li class=\"msword-table-list-bullet\"> The assessment for billing provider information in the OT file is based on all OT claims, rather than having separate assessments for institutional and professional claims. </li> <li class=\"msword-table-list-bullet\"> The measures and assessment associated with the Billing Provider Taxonomy and Specialty - RX topic are not calculated. </li> <li class=\"msword-table-list-bullet\"> The measures and assessment associated with the Servicing Provider Type, Specialty, and Taxonomy - OT Professional topic are not calculated. </li> <li class=\"msword-table-list-bullet\"> The measures and assessment associated with the Servicing Provider Type, Specialty, and Taxonomy - OT Institutional topic are not calculated. </li> <li class=\"msword-table-list-bullet\"> Records with missing place of service, type of bill and revenue codes are not classified as professional claims, even if they have a valid procedure code on all line records. </li> </ul> </td> </tr> <tr> <td> <ul> <li class=\"msword-table-list-bullet\"> 2014 Release 2 </li> <li class=\"msword-table-list-bullet\"> 2015 Release 2 </li> <li class=\"msword-table-list-bullet\"> 2016 Releases 1 and 2 </li> <li class=\"msword-table-list-bullet\"> 2017 Releases 1 and 2 </li> <li class=\"msword-table-list-bullet\"> 2018 Releases 1 and 2 </li> <li class=\"msword-table-list-bullet\"> 2019 Preliminary Release and Release 1 </li> <li class=\"msword-table-list-bullet\"> 2020 Preliminary Release </li> </ul> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> Zero-filled revenue code values are considered valid when distinguishing between institutional and professional claims. </li> <li class=\"msword-table-list-bullet\"> Contextual measures of the percentage of records with a valid or expected NPPES primary taxonomy code are not calculated. </li> </ul> </td> </tr> <tr> <td> <ul> <li class=\"msword-table-list-bullet\"> 2014 Release 2 </li> <li class=\"msword-table-list-bullet\"> 2015 Release 2 </li> <li class=\"msword-table-list-bullet\"> 2016 Releases 1 and 2 </li> <li class=\"msword-table-list-bullet\"> 2017 Releases 1 and 2 </li> <li class=\"msword-table-list-bullet\"> 2018 Releases 1 and 2 </li> <li class=\"msword-table-list-bullet\"> 2019 Preliminary Release and Release 1 </li> <li class=\"msword-table-list-bullet\"> 2020 Preliminary Release and Release 1 </li> <li class=\"msword-table-list-bullet\"> 2021 Preliminary Release </li> </ul> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> NPPES primary taxonomy code is not included in the DQ assessment criteria for the billing (IP, LT, OT) and servicing provider (OT) topics. </li> </ul> </td> </tr> </tbody></table><ol> <li class=\"footnoteBody\" id=\"footnote-2\" value=\"3\"> <p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources page</a> , and a crosswalk of variable names can be found in the guide &ldquo;Production of the TAF Research Identifiable Files.&rdquo; </p> <p> <a href=\"#footnote-ref-2\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-3\" value=\"4\"> <p class=\"msword-footnote-text\"> We used claim type code (CLM_TYPE_CD) to determine which records to include and exclude in our analysis. Records included are those with a claim type code indicating FFS claims (values of 1 and A) and managed care encounters (3 and C). We excluded capitated payments (2 and B), supplemental payments (5 and E), and service-tracking claims (4 and D). We also used claim type code to exclude &ldquo;other&rdquo; records (values of U, V, W, X, and Y) that the state did not classify as either Medicaid or CHIP payment records. More information on supplemental payments and other claims can be found in the DQ Atlas single topic display for <a aria-label=\"View DQ Atlas single topic display for Non-Program (Other) Claims\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g7m61\">Non-Program (Other) Claims</a> . </p> <p> <a href=\"#footnote-ref-3\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-4\" value=\"5\"> <p class=\"msword-footnote-text\"> More information about the completeness of each state&rsquo;s TAF data can be found in the DQ Atlas single topic displays for <a aria-label=\"View DQ Atlas single topic display for Claims Volume - IP\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g4m45\">Claims Volume&mdash;IP</a> , <a aria-label=\"View DQ Atlas single topic display for Claims Volume - LT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g4m46\">Claims Volume&mdash;LT</a> , <a aria-label=\"View DQ Atlas single topic display for Claims Volume - OT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g4m47\">Claims Volume&mdash;OT</a> , and <a aria-label=\"View DQ Atlas single topic display for Claims Volume - RX\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g4m48\">Claims Volume&mdash;RX</a> . </p> <p> <a href=\"#footnote-ref-4\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-5\" value=\"6\"> <p class=\"msword-footnote-text\"> Because of limitations in its claims processing system, Illinois captures adjustments to original claims as incremental credits or debits rather than voiding the original claim and submitting a replacement record with the new payment amount. As a result, the version of a record with the latest adjudication date may not represent the final action claim, as it does in all other states. To ensure that the TAF correctly captures all expenditures reported by Illinois into T-MSIS, all service use records are included in the IP, OT, LT, and RX files. This approach means that in some cases, the TAF will include multiple versions of a single claim for Illinois, so including all records in an analysis will overcount service utilization. To ensure that utilization counts are correct, we restricted our analysis to the original claim from each claim family by selecting only those records where ADJSTMT_IND = 0 and ADJSTMT_CLM_NUM = null. For more information, see the guide, &ldquo;How to Use Illinois Claims Data,&rdquo; on ResDAC.org. </p> <p> <a href=\"#footnote-ref-5\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-6\" value=\"7\"> <p class=\"msword-footnote-text\"> General hospitals may provide sub-acute care through &ldquo;swing beds&rdquo; or other non-acute units within the hospital, and we would expect these claims to be found in the LT file rather than the IP file. </p> <p> <a href=\"#footnote-ref-6\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-7\" value=\"8\"> <p class=\"msword-footnote-text\"> At least one state (Florida) allows Health Maintenance Organizations (HMOs) to dispense pharmaceuticals to enrollees. Therefore, HMOs are included as an &ldquo;expected&rdquo; taxonomy for RX billing providers. </p> <p> <a href=\"#footnote-ref-7\">&uarr;</a> </p> </li></ol>", "footnotes": [{"number": 2, "content": "<li class=\"footnoteBody\" id=\"footnote-2\" value=\"3\"><p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources page</a> , and a crosswalk of variable names can be found in the guide \u201cProduction of the TAF Research Identifiable Files.\u201d </p><p><a href=\"#footnote-ref-2\">\u2191</a></p></li>"}, {"number": 3, "content": "<li class=\"footnoteBody\" id=\"footnote-3\" value=\"4\"><p class=\"msword-footnote-text\"> We used claim type code (CLM_TYPE_CD) to determine which records to include and exclude in our analysis. Records included are those with a claim type code indicating FFS claims (values of 1 and A) and managed care encounters (3 and C). We excluded capitated payments (2 and B), supplemental payments (5 and E), and service-tracking claims (4 and D). We also used claim type code to exclude \u201cother\u201d records (values of U, V, W, X, and Y) that the state did not classify as either Medicaid or CHIP payment records. More information on supplemental payments and other claims can be found in the DQ Atlas single topic display for <a aria-label=\"View DQ Atlas single topic display for Non-Program (Other) Claims\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g7m61\">Non-Program (Other) Claims</a> . </p><p><a href=\"#footnote-ref-3\">\u2191</a></p></li>"}, {"number": 4, "content": "<li class=\"footnoteBody\" id=\"footnote-4\" value=\"5\"><p class=\"msword-footnote-text\"> More information about the completeness of each state\u2019s TAF data can be found in the DQ Atlas single topic displays for <a aria-label=\"View DQ Atlas single topic display for Claims Volume - IP\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g4m45\">Claims Volume\u2014IP</a> , <a aria-label=\"View DQ Atlas single topic display for Claims Volume - LT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g4m46\">Claims Volume\u2014LT</a> , <a aria-label=\"View DQ Atlas single topic display for Claims Volume - OT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g4m47\">Claims Volume\u2014OT</a> , and <a aria-label=\"View DQ Atlas single topic display for Claims Volume - RX\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g4m48\">Claims Volume\u2014RX</a> . </p><p><a href=\"#footnote-ref-4\">\u2191</a></p></li>"}, {"number": 5, "content": "<li class=\"footnoteBody\" id=\"footnote-5\" value=\"6\"><p class=\"msword-footnote-text\"> Because of limitations in its claims processing system, Illinois captures adjustments to original claims as incremental credits or debits rather than voiding the original claim and submitting a replacement record with the new payment amount. As a result, the version of a record with the latest adjudication date may not represent the final action claim, as it does in all other states. To ensure that the TAF correctly captures all expenditures reported by Illinois into T-MSIS, all service use records are included in the IP, OT, LT, and RX files. This approach means that in some cases, the TAF will include multiple versions of a single claim for Illinois, so including all records in an analysis will overcount service utilization. To ensure that utilization counts are correct, we restricted our analysis to the original claim from each claim family by selecting only those records where ADJSTMT_IND = 0 and ADJSTMT_CLM_NUM = null. For more information, see the guide, \u201cHow to Use Illinois Claims Data,\u201d on ResDAC.org. </p><p><a href=\"#footnote-ref-5\">\u2191</a></p></li>"}, {"number": 6, "content": "<li class=\"footnoteBody\" id=\"footnote-6\" value=\"7\"><p class=\"msword-footnote-text\"> General hospitals may provide sub-acute care through \u201cswing beds\u201d or other non-acute units within the hospital, and we would expect these claims to be found in the LT file rather than the IP file. </p><p><a href=\"#footnote-ref-6\">\u2191</a></p></li>"}, {"number": 7, "content": "<li class=\"footnoteBody\" id=\"footnote-7\" value=\"8\"><p class=\"msword-footnote-text\"> At least one state (Florida) allows Health Maintenance Organizations (HMOs) to dispense pharmaceuticals to enrollees. Therefore, HMOs are included as an \u201cexpected\u201d taxonomy for RX billing providers. </p><p><a href=\"#footnote-ref-7\">\u2191</a></p></li>"}]}, "summary": {"content": "<p>The billing provider type, specialty, and taxonomy codes allow TAF users to examine the characteristics of providers who bill and receive payments for Medicaid- and CHIP-funded services. This analysis examines the extent to which facility claims in the OT file have a billing provider type, specialty, or taxonomy missing or coded with unexpected or unusable values.</p>", "footnotes": []}, "originalIssueBriefId": "5081", "relatedTopics": [{"measureId": 37, "measureName": "Billing Provider Type, Specialty, and Taxonomy - IP", "groupId": 6, "groupName": "Provider Information", "order": 0}, {"measureId": 38, "measureName": "Billing Provider Type, Specialty, and Taxonomy - LT", "groupId": 6, "groupName": "Provider Information", "order": 1}, {"measureId": 104, "measureName": "Billing Provider Type, Specialty, and Taxonomy - OT Professional", "groupId": 6, "groupName": "Provider Information", "order": 2}, {"measureId": 103, "measureName": "Billing Provider Specialty and Taxonomy - RX", "groupId": 6, "groupName": "Provider Information", "order": 4}, {"measureId": 106, "measureName": "Servicing Provider Type, Specialty, and Taxonomy - OT Professional", "groupId": 6, "groupName": "Provider Information", "order": 5}, {"measureId": 107, "measureName": "Servicing Provider Type, Specialty, and Taxonomy - OT Institutional", "groupId": 6, "groupName": "Provider Information", "order": 6}]}
106
{"measureId": 106, "measureName": "Servicing Provider Type, Specialty, and Taxonomy - OT Professional", "groupId": 6, "groupName": "Provider Information", "pdfVersionLink": "downloads/background-and-methods/TAF-DQ-Serv-Prov-Type-OT-Prof.pdf", "background": {"content": "<p class=\"msword-paragraph\"> Users of the T-MSIS Analytic Files (TAF) may want to identify the providers or categories of providers that deliver services to Medicaid and Children&rsquo;s Health Insurance Program (CHIP) beneficiaries. A claim in the TAF could include information for up to six providers, depending on the file type. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-2\" id=\"footnote-ref-2\">[1]</a> </sup> </sup> A provider could be a facility, a group of individual practitioners, or an individual practitioner. The provider types most often used for claims-based analyses include the billing, servicing, prescribing, and dispensing providers.</p><p class=\"msword-paragraph\"> The billing provider represents the entity that submits the claim and is reimbursed by the Medicaid or CHIP agency. Information about the billing provider is available in all TAF claims files: inpatient (IP), long-term care (LT), other services (OT), and pharmacy (RX).</p><p class=\"msword-paragraph\"> The servicing provider, in contrast, represents the individual practitioner who was responsible for or provided direct care to the beneficiary (that is, the rendering provider). Information about servicing provider is available in the IP, LT, and OT files. In some cases, the servicing provider is the same as the billing provider. In other cases, the servicing and billing provider differ, such as when a hospital or large group practice bills for services but an individual physician employed by the hospital or group provides the direct care and is the serving provider. Because institutional claims in the IP and LT files represent facility costs and are often submitted by the hospitals and skilled nursing facilities where the care occurred, analyses using these claims would typically only use the billing provider information.</p><p class=\"msword-paragraph\"> For prescription drug claims, the billing provider is the pharmacy where the prescription was filled, the prescribing provider is the individual practitioner who prescribed a prescription drug to a beneficiary, and the dispensing provider is the pharmacist who filled the prescription or was responsible for overseeing the filling of the prescription. Because the billing provider represents the entity that submits a claim and is reimbursed by the Medicaid or CHIP agency, analyses using prescription drug claims typically focus on the billing provider information.</p><p class=\"msword-paragraph\"> Data elements related to the billing provider can offer insight into the characteristics of providers who receive payment for Medicaid- and CHIP-funded services. Likewise, data elements related to the servicing provider can offer insight into the characteristics of the individual practitioner who was responsible for or provided direct care to a Medicaid or CHIP beneficiary. There are multiple systems available in TAF claim records for classifying providers, including the following:</p><ul> <li class=\"msword-list-bullet\"> <strong> Provider taxonomy </strong> , which has detailed categories covering all facility, group, and individual provider types. All taxonomy codes must correspond to values from the National Uniform Claim Committee (NUCC) Health Care Provider Taxonomy code set. The billing and servicing provider information on TAF claim records include both the state-reported taxonomy and National Plan and Provider Enumeration System (NPPES) primary taxonomy. The state-reported taxonomy is reported by the provider on the claim form. The NPPES primary taxonomy is pulled from the NPPES data, which represents the information reported by the provider when applying for or updating their National Provider Identifier (NPI). </li> <li class=\"msword-list-bullet\"> <strong> Provider specialty </strong> , which has a limited number of categories for facility and non-physician providers but detailed categories for the physician specialty most relevant to individual physicians or group practices. This information is reported by the state in T-MSIS and is not pulled directly from the claim form. </li> <li class=\"msword-list-bullet\"> <strong> Provider type </strong> , which covers facility, physician, and non-physician providers who commonly participate in Medicaid. This information is reported by the state in T-MSIS and is not pulled directly from the claim form. </li></ul><p class=\"msword-paragraph\"> Each of these classification systems may be best suited to different types of analyses. Although states are encouraged to populate all these fields on all claims, only one classification type is required. In practice, some states only submit information related to some of the classification systems, which may require TAF users to adjust their methodology across states. If the preferred data element has high rates of missingness, TAF users may be able to link the claims record to the provider&rsquo;s record in the Annual Provider File (APR) to obtain the needed information. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-3\" id=\"footnote-ref-3\">[2]</a> </sup> </sup></p><p class=\"msword-paragraph\"> This data quality assessment examines whether any information on billing or servicing provider characteristics is available in claims records, and which type (taxonomy, specialty, or provider type). This information can help users design their analysis by selecting the fields populated in each state or identify states for which it may be necessary to link to the APR to obtain complete information about providers, rather than rely on claims alone.</p><p class=\"msword-paragraph\"></p><ol> <li class=\"footnoteBody\" id=\"footnote-2\" value=\"1\"> <p class=\"msword-footnote-text\"> The inpatient file includes information about billing, referring, servicing, admitting, and operating providers. The long-term care file includes information about billing, referring, servicing, and admitting providers. The other services file includes information about billing, referring, servicing, health home, directing, and supervising providers. The pharmacy claims file includes information about billing, dispensing, and prescribing providers. </p> <p> <a href=\"#footnote-ref-2\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-3\" value=\"2\"> <p class=\"msword-footnote-text\"> States are required to submit information about all providers eligible to provide Medicaid- and CHIP-funded services; these records are captured in the APR. It is possible that missing information in the claim about provider taxonomy, specialty, or type could be imputed by linking to the provider&rsquo;s record in the APR and obtaining the information from that file. In addition, the APR includes information on how states classify providers by &ldquo;authorized category of service,&rdquo; a classification scheme that can be used to identify certain non-medical provider categories not captured in the other classification systems, such as transportation or personal care service providers. For more information on the completeness of these fields in each state&rsquo;s APR file, see the DQ Atlas single-topic displays for <a aria-label=\"View DQ Atlas single topic display for Group and Individual Providers - Classification Types\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g6m95\">Group and Individual Providers - Classification Types</a> and <a aria-label=\"View DQ Atlas single topic display for Facilities - Classification Types\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g6m97\">Facilities - Classification Types</a> . </p> <p> <a href=\"#footnote-ref-3\">&uarr;</a> </p> </li></ol>", "footnotes": [{"number": 2, "content": "<li class=\"footnoteBody\" id=\"footnote-2\" value=\"1\"><p class=\"msword-footnote-text\"> The inpatient file includes information about billing, referring, servicing, admitting, and operating providers. The long-term care file includes information about billing, referring, servicing, and admitting providers. The other services file includes information about billing, referring, servicing, health home, directing, and supervising providers. The pharmacy claims file includes information about billing, dispensing, and prescribing providers. </p><p><a href=\"#footnote-ref-2\">\u2191</a></p></li>"}, {"number": 3, "content": "<li class=\"footnoteBody\" id=\"footnote-3\" value=\"2\"><p class=\"msword-footnote-text\"> States are required to submit information about all providers eligible to provide Medicaid- and CHIP-funded services; these records are captured in the APR. It is possible that missing information in the claim about provider taxonomy, specialty, or type could be imputed by linking to the provider\u2019s record in the APR and obtaining the information from that file. In addition, the APR includes information on how states classify providers by \u201cauthorized category of service,\u201d a classification scheme that can be used to identify certain non-medical provider categories not captured in the other classification systems, such as transportation or personal care service providers. For more information on the completeness of these fields in each state\u2019s APR file, see the DQ Atlas single-topic displays for <a aria-label=\"View DQ Atlas single topic display for Group and Individual Providers - Classification Types\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g6m95\">Group and Individual Providers - Classification Types</a> and <a aria-label=\"View DQ Atlas single topic display for Facilities - Classification Types\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g6m97\">Facilities - Classification Types</a> . </p><p><a href=\"#footnote-ref-3\">\u2191</a></p></li>"}]}, "methods": {"content": "<p class=\"msword-callout\"> The following describes current methods used to assess data quality. Information about methods previously used to assess data quality can be found at the bottom of this section.</p><p class=\"msword-paragraph\"> We examined the values for provider type, specialty, and taxonomy codes for the providers most examined in analyses for the TAF IP, LT, OT, and RX files (Table 1). <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-2\" id=\"footnote-ref-2\">[3]</a> </sup> </sup> We included both fee-for-service (FFS) claims and managed care encounter records, which represent claims paid by managed care organizations and should generally follow the same reporting standards for billing and servicing providers. We excluded financial transaction records, supplemental payments, and &ldquo;other&rdquo; records that the state did not classify as being covered by either the Medicaid or CHIP programs. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-3\" id=\"footnote-ref-3\">[4]</a> </sup> </sup> <sup> &nbsp; </sup> We also excluded states from the analysis of each file if the number of header records in the TAF was low enough to be unusable. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-4\" id=\"footnote-ref-4\">[5]</a> </sup> </sup> <sup> &nbsp; </sup> For Illinois, we restricted our analysis to the original version of the claim and excluded all subsequent adjustment records in the state&rsquo;s TAF data. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-5\" id=\"footnote-ref-5\">[6]</a> </sup> </sup></p><p class=\"msword-table-title\"> Table 1. Crosswalk between file type, data element description, and TAF variable name</p><table aria-label=\"Table 1. Crosswalk between file type, data element description, and TAF variable name\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> File type </p> </th> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Data element description </p> </th> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Variable name </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> IP, LT, OT </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Billing provider </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> BLG_PRVDR_TYPE_CD </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> IP, LT, OT, RX </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Billing provider specialty code </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> BLG_PRVDR_SPCLTY_CD </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> IP, LT, OT, RX </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Billing provider state-reported taxonomy code </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> BLG_PRVDR_TXNMY_CD </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> IP, LT, OT </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Billing provider NPPES primary taxonomy code </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> BLG_PRVDR_NPPES_TXNMY_CD </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> OT </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Servicing provider type code </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> SRVCNG_PRVDR_TYPE_CD </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> OT </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Servicing provider specialty code </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> SRVCNG_PRVDR_SPCLTY_CD </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> OT </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Servicing provider state-reported taxonomy code </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> SRVCNG_PRVDR_TXNMY_CD </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> OT </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Servicing provider NPPES primary taxonomy code </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> SRVCNG_PRVDR_NPPES_TXNMY_CD </p> </td> </tr> </tbody></table><p class=\"msword-paragraph\"> The provider type code includes 57 different valid values, covering both facilities and professionals. As shown in Table 2, we grouped these values into those that are expected, unexpected, and unusable for billing providers for each of the three file types in which this data element is present (IP, LT, OT) and for servicing providers in the OT file.</p><p class=\"msword-paragraph\"> In the IP file, we would expect to see only general hospitals and Indian Health Service facilities as billing providers. In the LT file, we would expect to see nursing facilities, intermediate care facilities for individuals with intellectual or developmental disabilities, and psychiatric facilities as billing providers, as well as general hospitals in selected cases. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-6\" id=\"footnote-ref-6\">[7]</a> </sup> </sup> <sup class=\"msword-footnote-reference\"> &nbsp; </sup> In the OT file, we would expect to see a broad range of both facilities and professionals billing for and directly providing services.</p><p class=\"msword-paragraph\"> For all three files, we examined the &ldquo;all other&rdquo; code separately from the expected and unexpected categories. In some instances, use of the non-specific &ldquo;all other&rdquo; code may reflect the possibility that the provider is not represented in the list of valid provider type codes, which is the case for certain types of home- and community-based services (HCBS) and non-emergency medical transport providers. Although this code is valid and not considered an unexpected value in any file, it does not provide any information about the billing or servicing provider and thus renders the data element unusable for analysis.</p><p class=\"msword-table-title\"> Table 2. Classification of provider type codes, by file and provider field</p><table aria-label=\"Table 2. Classification of provider type codes, by file and provider field\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> File and provider field </p> </th> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Expected codes </p> </th> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Unusable codes (&ldquo;all other&rdquo; value) </p> </th> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Unexpected codes </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> IP&mdash;billing provider </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 42, 51 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 57 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> All other values </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> LT&mdash;billing provider </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 42, 43, 44, 45 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 57 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> All other values </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> OT&mdash;billing and servicing provider </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 01&minus;56 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 57 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> None </p> </td> </tr> </tbody></table><p class=\"msword-table-source\"> Source: A full list of values is available in the TAF Claims Codebook at&nbsp; <a aria-label=\"View the TAF Claims Codebook on the Chronic Conditions Data Warehouse Data Dictionaries page\" href=\"https://www2.ccwdata.org/web/guest/data-dictionaries\">https://www2.ccwdata.org/web/guest/data-dictionaries</a> . The provider type code values are identical across all three files.</p><p class=\"msword-paragraph\"> The provider specialty code includes 115 different valid values, covering both facilities and professionals. As shown in Table 3, we grouped these values into those that are expected and unexpected for each of the file types and provider fields. In the IP file, we would expect to see only general hospitals as billing providers. In the LT file, we would expect to see nursing facilities, intermediate care facilities for individuals with intellectual or developmental disabilities, and psychiatric facilities as billing providers, as well as general hospitals in selected cases. <sup> &nbsp; </sup> In the OT file, we would expect to see a broad range of both facilities and professionals billing for and directly providing services. In the RX file, we would expect to see pharmacies, medical supply companies, department stores, and grocery stores as billing providers. For all files and provider fields, we examined the &ldquo;all other&rdquo; codes (billing provider specialty code 87&mdash;All Other Suppliers) separately from the expected and unexpected categories. Although this code is valid and not considered an unexpected value in any file, it does not provide any information about the provider and thus renders the data element unusable for analysis.</p><p class=\"msword-table-title\"> Table 3. Classification of provider specialty codes, by file and provider field</p><table aria-label=\"Table 3. Classification of provider specialty codes, by file and provider field\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> File and provider field </p> </th> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Expected codes </p> </th> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Unusable codes (&ldquo;all other&rdquo; value) </p> </th> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Unexpected codes </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> IP&mdash;billing provider </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> A0 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 87 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> All other values except 88 and 99, which are treated as missing </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> LT&mdash;billing provider </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> A0, A1, A2, A3, B4 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 87 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> All other values except 88 and 99, which are treated as missing </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> OT&mdash;billing and servicing provider </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 1&minus;86, 89&minus;98, A0&minus;B5 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 87 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> All other values except 88 and 99, which are treated as missing </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> RX&mdash;billing provider </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 51&ndash;54, 58, 73, A5, A6, A9, B1, B3, B4 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 87 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> All other values except 88 and 99, which are treated as missing </p> </td> </tr> </tbody></table><p class=\"msword-table-source\"> Source: A full list of values is available in the TAF Claims Codebook at&nbsp; <a aria-label=\"View the TAF Claims Codebook on the Chronic Conditions Data Warehouse Data Dictionaries page\" href=\"https://www2.ccwdata.org/web/guest/data-dictionaries\">https://www2.ccwdata.org/web/guest/data-dictionaries</a> . The provider specialty code values are identical across all claims files.</p><p class=\"msword-paragraph\"> The state-reported billing provider taxonomy code is a 10-character alphanumeric code that identifies the provider&rsquo;s area of specialization. As shown in Table 4, we grouped these values into those that are expected and unexpected for each of the file types. In the IP file, we would expect to see inpatient hospitals as billing providers. In the LT files we would expect to see nursing facilities, intermediate care facility services for individuals with intellectual disabilities, mental health facility services, and independent (free-standing) psychiatric wings of acute care hospitals as billing providers. In the OT file, we would expect to see a broad range of both facilities and professionals billing for and directly providing services. In the RX file, we would expect to see pharmacies and other suppliers as billing providers.</p><p class=\"msword-paragraph\"> In addition to the state-reported provider taxonomy codes, IP, OT and LT files produced in 2022 and later years also include a constructed taxonomy variable for billing and servicing providers, the NPPES primary taxonomy code (*_NPPES_TXNMY_CD), that represents the provider&rsquo;s primary taxonomy information as reported in the National Plan and Provider Enumeration System (NPPES) based on the provider&rsquo;s National Provider Identifier. We used the same criteria as the state-reported taxonomy codes to determine expected and unexpected values for each file type.</p><p class=\"msword-table-title\"> Table 4. Classification of provider taxonomy codes, by file and provider field</p><table aria-label=\"Table 4. Classification of provider taxonomy codes, by file and provider field\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> File and provider field </p> </th> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Expected codes </p> </th> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Unexpected codes </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> IP&mdash;billing provider </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> First 2 digits of taxonomy code are 27 or 28 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> All other values </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> LT&mdash;billing provider </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Taxonomy code begins with 283Q, 283X, 282E, 31, 32, 385H, or 281P </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> All other values </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> OT&mdash;billing and servicing provider </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> All valid taxonomy codes </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> None </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> RX&mdash;billing provider </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> First 2 digits of taxonomy code are 33, first 3 digits are 183, or 302R00000X <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-7\" id=\"footnote-ref-7\">[8]</a> </sup> </sup> </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> All other values </p> </td> </tr> </tbody></table><p class=\"msword-table-source\"> Source: The health care provider taxonomy code set can be found at <a aria-label=\"View the 2019 Health Care Provider Taxonomy Code Set\" href=\"http://www.wpc-edi.com/reference/codelists/healthcare/health-care-provider-taxonomy-code-set/\">http://www.wpc-edi.com/reference/codelists/healthcare/health-care-provider-taxonomy-code-set/</a> . The provider taxonomy code values are identical across all claims files.</p><p class=\"msword-paragraph\"> We grouped states into categories of low, medium, and high concern about the usability of their data, based on the percentage of header records (or for servicing providers in the OT file, claim lines) that had an expected provider type, specialty, state-reported taxonomy code, or NPPES primary taxonomy code for the file and provider fields (Table 5).</p><p class=\"msword-paragraph\"> Because users of the OT file may be interested in professional or institutional (facility) claims, we conducted the DQ assessment separately for each of these claim types. Table 6 shows the methodology used to classify each claim header as a professional or institutional claim. Any claim that did not meet at least one of the criteria for a professional or institutional claim was considered unclassified and is not included in this analysis. Note that the servicing provider analyses were conducted at the claim line level, but the claims were classified as professional or institutional claims at the claim header level.</p><p class=\"msword-table-title\"> Table 5. Criteria for DQ assessment of provider type, specialty, and taxonomy code</p><table aria-label=\"Table 5. Criteria for DQ assessment of provider type, specialty, and taxonomy code\" class=\"dq-assessment-table\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Percentage of records with an expected provider type, specialty, state-reported taxonomy code, or NPPES primary taxonomy code </p> </th> <th class=\"msword-table-header-left dq-assessment-col\"> <p class=\"msword-table-header-left\"> DQ assessment </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &ge; 90 percent </p> </td> <td class=\"msword-table-text-left dq-assessment-col dq-level low\"> <p class=\"msword-table-text-left\"> Low concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 80 percent &le; x &lt; 90 percent </p> </td> <td class=\"msword-table-text-left dq-assessment-col dq-level medium\"> <p class=\"msword-table-text-left\"> Medium concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 50 percent &le; x &lt; 80 percent </p> </td> <td class=\"msword-table-text-left dq-assessment-col dq-level high\"> <p class=\"msword-table-text-left\"> High concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &lt; 50 percent </p> </td> <td class=\"msword-table-text-left dq-assessment-col dq-level unusable\"> <p class=\"msword-table-text-left\"> Unusable </p> </td> </tr> </tbody></table><p class=\"msword-table-title\"> Table 6. Classification of OT claim headers as professional or facility claims</p><table aria-label=\"Table 6. Classification of OT claim headers as professional or facility claims\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Claim category </p> </th> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Identification rules </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Professional </p> </td> <td> <p class=\"msword-table-text-left\"> The record must meet at least one of the following criteria: </p> <ul> <li class=\"msword-table-list-bullet\"> Has a valid place of service code on the header record and a missing or invalid revenue code on all line records </li> <li class=\"msword-table-list-bullet\"> Has a missing or invalid place of service code in the header record, a missing or invalid type of bill code in the header record, and a missing or invalid revenue code plus a valid procedure code in all line records </li> </ul> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Institutional </p> </td> <td> <p class=\"msword-table-text-left\"> The record must meet at least one of the following criteria: </p> <ul> <li class=\"msword-table-list-bullet\"> Has at least one line with a valid revenue code </li> <li class=\"msword-table-list-bullet\"> Has a valid type of bill code and a missing or invalid place of service code </li> </ul> </td> </tr> </tbody></table><p class=\"msword-header\"> Methods previously used to assess data quality</p><p> <a id=\"_Hlk71024897\"></a> Table 7 includes information about methods previously used to assess data quality and the data years and versions assessed using those methods. Each table record describes how the assessment methods for the listed data years and versions differ from current methods. Aside from those differences, the assessments for these data years and versions align with current methods. All data years and versions not listed in the table are assessed using current methods.</p><p class=\"msword-table-title\"> Table 7. Previously used methods and applicable data years and versions</p><table aria-label=\"Table 7. Previously used methods and applicable data years and versions\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Data year(s) and version(s) </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Description of difference(s) from current methods </p> </th> </tr> </thead> <tbody> <tr> <td> <ul> <li class=\"msword-table-list-bullet\"> 2014 Release 2 </li> <li class=\"msword-table-list-bullet\"> 2015 Release 2 </li> <li class=\"msword-table-list-bullet\"> 2016 Releases 1 and 2 </li> <li class=\"msword-table-list-bullet\"> 2017 Releases 1 and 2 </li> <li class=\"msword-table-list-bullet\"> 2018 Releases 1 and 2 </li> <li class=\"msword-table-list-bullet\"> 2019 Preliminary Release and Release 1 </li> </ul> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> The assessments of billing provider information for the IP, LT, and OT file are only based on the percentage of claims with an expected billing provider type code. Measures related to billing provider taxonomy code and billing provider specialty code are not calculated or included in the assessments. </li> <li class=\"msword-table-list-bullet\"> The assessment for billing provider information in the OT file is based on all OT claims, rather than having separate assessments for institutional and professional claims. </li> <li class=\"msword-table-list-bullet\"> The measures and assessment associated with the Billing Provider Taxonomy and Specialty - RX topic are not calculated. </li> <li class=\"msword-table-list-bullet\"> The measures and assessment associated with the Servicing Provider Type, Specialty, and Taxonomy - OT Professional topic are not calculated. </li> <li class=\"msword-table-list-bullet\"> The measures and assessment associated with the Servicing Provider Type, Specialty, and Taxonomy - OT Institutional topic are not calculated. </li> <li class=\"msword-table-list-bullet\"> Records with missing place of service, type of bill and revenue codes are not classified as professional claims, even if they have a valid procedure code on all line records. </li> </ul> </td> </tr> <tr> <td> <ul> <li class=\"msword-table-list-bullet\"> 2014 Release 2 </li> <li class=\"msword-table-list-bullet\"> 2015 Release 2 </li> <li class=\"msword-table-list-bullet\"> 2016 Releases 1 and 2 </li> <li class=\"msword-table-list-bullet\"> 2017 Releases 1 and 2 </li> <li class=\"msword-table-list-bullet\"> 2018 Releases 1 and 2 </li> <li class=\"msword-table-list-bullet\"> 2019 Preliminary Release and Release 1 </li> <li class=\"msword-table-list-bullet\"> 2020 Preliminary Release </li> </ul> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> Zero-filled revenue code values are considered valid when distinguishing between institutional and professional claims. </li> <li class=\"msword-table-list-bullet\"> Contextual measures of the percentage of records with a valid or expected NPPES primary taxonomy code are not calculated. </li> </ul> </td> </tr> <tr> <td> <ul> <li class=\"msword-table-list-bullet\"> 2014 Release 2 </li> <li class=\"msword-table-list-bullet\"> 2015 Release 2 </li> <li class=\"msword-table-list-bullet\"> 2016 Releases 1 and 2 </li> <li class=\"msword-table-list-bullet\"> 2017 Releases 1 and 2 </li> <li class=\"msword-table-list-bullet\"> 2018 Releases 1 and 2 </li> <li class=\"msword-table-list-bullet\"> 2019 Preliminary Release and Release 1 </li> <li class=\"msword-table-list-bullet\"> 2020 Preliminary Release and Release 1 </li> <li class=\"msword-table-list-bullet\"> 2021 Preliminary Release </li> </ul> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> NPPES primary taxonomy code is not included in the DQ assessment criteria for the billing (IP, LT, OT) and servicing provider (OT) topics. </li> </ul> </td> </tr> </tbody></table><ol> <li class=\"footnoteBody\" id=\"footnote-2\" value=\"3\"> <p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources page</a> , and a crosswalk of variable names can be found in the guide &ldquo;Production of the TAF Research Identifiable Files.&rdquo; </p> <p> <a href=\"#footnote-ref-2\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-3\" value=\"4\"> <p class=\"msword-footnote-text\"> We used claim type code (CLM_TYPE_CD) to determine which records to include and exclude in our analysis. Records included are those with a claim type code indicating FFS claims (values of 1 and A) and managed care encounters (3 and C). We excluded capitated payments (2 and B), supplemental payments (5 and E), and service-tracking claims (4 and D). We also used claim type code to exclude &ldquo;other&rdquo; records (values of U, V, W, X, and Y) that the state did not classify as either Medicaid or CHIP payment records. More information on supplemental payments and other claims can be found in the DQ Atlas single topic display for <a aria-label=\"View DQ Atlas single topic display for Non-Program (Other) Claims\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g7m61\">Non-Program (Other) Claims</a> . </p> <p> <a href=\"#footnote-ref-3\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-4\" value=\"5\"> <p class=\"msword-footnote-text\"> More information about the completeness of each state&rsquo;s TAF data can be found in the DQ Atlas single topic displays for <a aria-label=\"View DQ Atlas single topic display for Claims Volume - IP\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g4m45\">Claims Volume&mdash;IP</a> , <a aria-label=\"View DQ Atlas single topic display for Claims Volume - LT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g4m46\">Claims Volume&mdash;LT</a> , <a aria-label=\"View DQ Atlas single topic display for Claims Volume - OT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g4m47\">Claims Volume&mdash;OT</a> , and <a aria-label=\"View DQ Atlas single topic display for Claims Volume - RX\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g4m48\">Claims Volume&mdash;RX</a> . </p> <p> <a href=\"#footnote-ref-4\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-5\" value=\"6\"> <p class=\"msword-footnote-text\"> Because of limitations in its claims processing system, Illinois captures adjustments to original claims as incremental credits or debits rather than voiding the original claim and submitting a replacement record with the new payment amount. As a result, the version of a record with the latest adjudication date may not represent the final action claim, as it does in all other states. To ensure that the TAF correctly captures all expenditures reported by Illinois into T-MSIS, all service use records are included in the IP, OT, LT, and RX files. This approach means that in some cases, the TAF will include multiple versions of a single claim for Illinois, so including all records in an analysis will overcount service utilization. To ensure that utilization counts are correct, we restricted our analysis to the original claim from each claim family by selecting only those records where ADJSTMT_IND = 0 and ADJSTMT_CLM_NUM = null. For more information, see the guide, &ldquo;How to Use Illinois Claims Data,&rdquo; on ResDAC.org. </p> <p> <a href=\"#footnote-ref-5\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-6\" value=\"7\"> <p class=\"msword-footnote-text\"> General hospitals may provide sub-acute care through &ldquo;swing beds&rdquo; or other non-acute units within the hospital, and we would expect these claims to be found in the LT file rather than the IP file. </p> <p> <a href=\"#footnote-ref-6\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-7\" value=\"8\"> <p class=\"msword-footnote-text\"> At least one state (Florida) allows Health Maintenance Organizations (HMOs) to dispense pharmaceuticals to enrollees. Therefore, HMOs are included as an &ldquo;expected&rdquo; taxonomy for RX billing providers. </p> <p> <a href=\"#footnote-ref-7\">&uarr;</a> </p> </li></ol>", "footnotes": [{"number": 2, "content": "<li class=\"footnoteBody\" id=\"footnote-2\" value=\"3\"><p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources page</a> , and a crosswalk of variable names can be found in the guide \u201cProduction of the TAF Research Identifiable Files.\u201d </p><p><a href=\"#footnote-ref-2\">\u2191</a></p></li>"}, {"number": 3, "content": "<li class=\"footnoteBody\" id=\"footnote-3\" value=\"4\"><p class=\"msword-footnote-text\"> We used claim type code (CLM_TYPE_CD) to determine which records to include and exclude in our analysis. Records included are those with a claim type code indicating FFS claims (values of 1 and A) and managed care encounters (3 and C). We excluded capitated payments (2 and B), supplemental payments (5 and E), and service-tracking claims (4 and D). We also used claim type code to exclude \u201cother\u201d records (values of U, V, W, X, and Y) that the state did not classify as either Medicaid or CHIP payment records. More information on supplemental payments and other claims can be found in the DQ Atlas single topic display for <a aria-label=\"View DQ Atlas single topic display for Non-Program (Other) Claims\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g7m61\">Non-Program (Other) Claims</a> . </p><p><a href=\"#footnote-ref-3\">\u2191</a></p></li>"}, {"number": 4, "content": "<li class=\"footnoteBody\" id=\"footnote-4\" value=\"5\"><p class=\"msword-footnote-text\"> More information about the completeness of each state\u2019s TAF data can be found in the DQ Atlas single topic displays for <a aria-label=\"View DQ Atlas single topic display for Claims Volume - IP\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g4m45\">Claims Volume\u2014IP</a> , <a aria-label=\"View DQ Atlas single topic display for Claims Volume - LT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g4m46\">Claims Volume\u2014LT</a> , <a aria-label=\"View DQ Atlas single topic display for Claims Volume - OT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g4m47\">Claims Volume\u2014OT</a> , and <a aria-label=\"View DQ Atlas single topic display for Claims Volume - RX\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g4m48\">Claims Volume\u2014RX</a> . </p><p><a href=\"#footnote-ref-4\">\u2191</a></p></li>"}, {"number": 5, "content": "<li class=\"footnoteBody\" id=\"footnote-5\" value=\"6\"><p class=\"msword-footnote-text\"> Because of limitations in its claims processing system, Illinois captures adjustments to original claims as incremental credits or debits rather than voiding the original claim and submitting a replacement record with the new payment amount. As a result, the version of a record with the latest adjudication date may not represent the final action claim, as it does in all other states. To ensure that the TAF correctly captures all expenditures reported by Illinois into T-MSIS, all service use records are included in the IP, OT, LT, and RX files. This approach means that in some cases, the TAF will include multiple versions of a single claim for Illinois, so including all records in an analysis will overcount service utilization. To ensure that utilization counts are correct, we restricted our analysis to the original claim from each claim family by selecting only those records where ADJSTMT_IND = 0 and ADJSTMT_CLM_NUM = null. For more information, see the guide, \u201cHow to Use Illinois Claims Data,\u201d on ResDAC.org. </p><p><a href=\"#footnote-ref-5\">\u2191</a></p></li>"}, {"number": 6, "content": "<li class=\"footnoteBody\" id=\"footnote-6\" value=\"7\"><p class=\"msword-footnote-text\"> General hospitals may provide sub-acute care through \u201cswing beds\u201d or other non-acute units within the hospital, and we would expect these claims to be found in the LT file rather than the IP file. </p><p><a href=\"#footnote-ref-6\">\u2191</a></p></li>"}, {"number": 7, "content": "<li class=\"footnoteBody\" id=\"footnote-7\" value=\"8\"><p class=\"msword-footnote-text\"> At least one state (Florida) allows Health Maintenance Organizations (HMOs) to dispense pharmaceuticals to enrollees. Therefore, HMOs are included as an \u201cexpected\u201d taxonomy for RX billing providers. </p><p><a href=\"#footnote-ref-7\">\u2191</a></p></li>"}]}, "summary": {"content": "<p>The servicing provider type, specialty, and taxonomy codes allow TAF users to examine the characteristics of the individual practitioner who was responsible for or provided direct care to a Medicaid or CHIP beneficiary. This analysis examines the extent to which professional claims in the OT file have a servicing provider type, specialty, and taxonomy missing or coded with unexpected or unusable values.</p>", "footnotes": []}, "originalIssueBriefId": "5081", "relatedTopics": [{"measureId": 37, "measureName": "Billing Provider Type, Specialty, and Taxonomy - IP", "groupId": 6, "groupName": "Provider Information", "order": 0}, {"measureId": 38, "measureName": "Billing Provider Type, Specialty, and Taxonomy - LT", "groupId": 6, "groupName": "Provider Information", "order": 1}, {"measureId": 104, "measureName": "Billing Provider Type, Specialty, and Taxonomy - OT Professional", "groupId": 6, "groupName": "Provider Information", "order": 2}, {"measureId": 105, "measureName": "Billing Provider Type, Specialty, and Taxonomy - OT Institutional", "groupId": 6, "groupName": "Provider Information", "order": 3}, {"measureId": 103, "measureName": "Billing Provider Specialty and Taxonomy - RX", "groupId": 6, "groupName": "Provider Information", "order": 4}, {"measureId": 107, "measureName": "Servicing Provider Type, Specialty, and Taxonomy - OT Institutional", "groupId": 6, "groupName": "Provider Information", "order": 6}]}
107
{"measureId": 107, "measureName": "Servicing Provider Type, Specialty, and Taxonomy - OT Institutional", "groupId": 6, "groupName": "Provider Information", "pdfVersionLink": "downloads/background-and-methods/TAF-DQ-Serv-Prov-Type-OT-Inst.pdf", "background": {"content": "<p class=\"msword-paragraph\"> Users of the T-MSIS Analytic Files (TAF) may want to identify the providers or categories of providers that deliver services to Medicaid and Children&rsquo;s Health Insurance Program (CHIP) beneficiaries. A claim in the TAF could include information for up to six providers, depending on the file type. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-2\" id=\"footnote-ref-2\">[1]</a> </sup> </sup> A provider could be a facility, a group of individual practitioners, or an individual practitioner. The provider types most often used for claims-based analyses include the billing, servicing, prescribing, and dispensing providers.</p><p class=\"msword-paragraph\"> The billing provider represents the entity that submits the claim and is reimbursed by the Medicaid or CHIP agency. Information about the billing provider is available in all TAF claims files: inpatient (IP), long-term care (LT), other services (OT), and pharmacy (RX).</p><p class=\"msword-paragraph\"> The servicing provider, in contrast, represents the individual practitioner who was responsible for or provided direct care to the beneficiary (that is, the rendering provider). Information about servicing provider is available in the IP, LT, and OT files. In some cases, the servicing provider is the same as the billing provider. In other cases, the servicing and billing provider differ, such as when a hospital or large group practice bills for services but an individual physician employed by the hospital or group provides the direct care and is the serving provider. Because institutional claims in the IP and LT files represent facility costs and are often submitted by the hospitals and skilled nursing facilities where the care occurred, analyses using these claims would typically only use the billing provider information.</p><p class=\"msword-paragraph\"> For prescription drug claims, the billing provider is the pharmacy where the prescription was filled, the prescribing provider is the individual practitioner who prescribed a prescription drug to a beneficiary, and the dispensing provider is the pharmacist who filled the prescription or was responsible for overseeing the filling of the prescription. Because the billing provider represents the entity that submits a claim and is reimbursed by the Medicaid or CHIP agency, analyses using prescription drug claims typically focus on the billing provider information.</p><p class=\"msword-paragraph\"> Data elements related to the billing provider can offer insight into the characteristics of providers who receive payment for Medicaid- and CHIP-funded services. Likewise, data elements related to the servicing provider can offer insight into the characteristics of the individual practitioner who was responsible for or provided direct care to a Medicaid or CHIP beneficiary. There are multiple systems available in TAF claim records for classifying providers, including the following:</p><ul> <li class=\"msword-list-bullet\"> <strong> Provider taxonomy </strong> , which has detailed categories covering all facility, group, and individual provider types. All taxonomy codes must correspond to values from the National Uniform Claim Committee (NUCC) Health Care Provider Taxonomy code set. The billing and servicing provider information on TAF claim records include both the state-reported taxonomy and National Plan and Provider Enumeration System (NPPES) primary taxonomy. The state-reported taxonomy is reported by the provider on the claim form. The NPPES primary taxonomy is pulled from the NPPES data, which represents the information reported by the provider when applying for or updating their National Provider Identifier (NPI). </li> <li class=\"msword-list-bullet\"> <strong> Provider specialty </strong> , which has a limited number of categories for facility and non-physician providers but detailed categories for the physician specialty most relevant to individual physicians or group practices. This information is reported by the state in T-MSIS and is not pulled directly from the claim form. </li> <li class=\"msword-list-bullet\"> <strong> Provider type </strong> , which covers facility, physician, and non-physician providers who commonly participate in Medicaid. This information is reported by the state in T-MSIS and is not pulled directly from the claim form. </li></ul><p class=\"msword-paragraph\"> Each of these classification systems may be best suited to different types of analyses. Although states are encouraged to populate all these fields on all claims, only one classification type is required. In practice, some states only submit information related to some of the classification systems, which may require TAF users to adjust their methodology across states. If the preferred data element has high rates of missingness, TAF users may be able to link the claims record to the provider&rsquo;s record in the Annual Provider File (APR) to obtain the needed information. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-3\" id=\"footnote-ref-3\">[2]</a> </sup> </sup></p><p class=\"msword-paragraph\"> This data quality assessment examines whether any information on billing or servicing provider characteristics is available in claims records, and which type (taxonomy, specialty, or provider type). This information can help users design their analysis by selecting the fields populated in each state or identify states for which it may be necessary to link to the APR to obtain complete information about providers, rather than rely on claims alone.</p><p class=\"msword-paragraph\"></p><ol> <li class=\"footnoteBody\" id=\"footnote-2\" value=\"1\"> <p class=\"msword-footnote-text\"> The inpatient file includes information about billing, referring, servicing, admitting, and operating providers. The long-term care file includes information about billing, referring, servicing, and admitting providers. The other services file includes information about billing, referring, servicing, health home, directing, and supervising providers. The pharmacy claims file includes information about billing, dispensing, and prescribing providers. </p> <p> <a href=\"#footnote-ref-2\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-3\" value=\"2\"> <p class=\"msword-footnote-text\"> States are required to submit information about all providers eligible to provide Medicaid- and CHIP-funded services; these records are captured in the APR. It is possible that missing information in the claim about provider taxonomy, specialty, or type could be imputed by linking to the provider&rsquo;s record in the APR and obtaining the information from that file. In addition, the APR includes information on how states classify providers by &ldquo;authorized category of service,&rdquo; a classification scheme that can be used to identify certain non-medical provider categories not captured in the other classification systems, such as transportation or personal care service providers. For more information on the completeness of these fields in each state&rsquo;s APR file, see the DQ Atlas single-topic displays for <a aria-label=\"View DQ Atlas single topic display for Group and Individual Providers - Classification Types\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g6m95\">Group and Individual Providers - Classification Types</a> and <a aria-label=\"View DQ Atlas single topic display for Facilities - Classification Types\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g6m97\">Facilities - Classification Types</a> . </p> <p> <a href=\"#footnote-ref-3\">&uarr;</a> </p> </li></ol>", "footnotes": [{"number": 2, "content": "<li class=\"footnoteBody\" id=\"footnote-2\" value=\"1\"><p class=\"msword-footnote-text\"> The inpatient file includes information about billing, referring, servicing, admitting, and operating providers. The long-term care file includes information about billing, referring, servicing, and admitting providers. The other services file includes information about billing, referring, servicing, health home, directing, and supervising providers. The pharmacy claims file includes information about billing, dispensing, and prescribing providers. </p><p><a href=\"#footnote-ref-2\">\u2191</a></p></li>"}, {"number": 3, "content": "<li class=\"footnoteBody\" id=\"footnote-3\" value=\"2\"><p class=\"msword-footnote-text\"> States are required to submit information about all providers eligible to provide Medicaid- and CHIP-funded services; these records are captured in the APR. It is possible that missing information in the claim about provider taxonomy, specialty, or type could be imputed by linking to the provider\u2019s record in the APR and obtaining the information from that file. In addition, the APR includes information on how states classify providers by \u201cauthorized category of service,\u201d a classification scheme that can be used to identify certain non-medical provider categories not captured in the other classification systems, such as transportation or personal care service providers. For more information on the completeness of these fields in each state\u2019s APR file, see the DQ Atlas single-topic displays for <a aria-label=\"View DQ Atlas single topic display for Group and Individual Providers - Classification Types\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g6m95\">Group and Individual Providers - Classification Types</a> and <a aria-label=\"View DQ Atlas single topic display for Facilities - Classification Types\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g6m97\">Facilities - Classification Types</a> . </p><p><a href=\"#footnote-ref-3\">\u2191</a></p></li>"}]}, "methods": {"content": "<p class=\"msword-callout\"> The following describes current methods used to assess data quality. Information about methods previously used to assess data quality can be found at the bottom of this section.</p><p class=\"msword-paragraph\"> We examined the values for provider type, specialty, and taxonomy codes for the providers most examined in analyses for the TAF IP, LT, OT, and RX files (Table 1). <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-2\" id=\"footnote-ref-2\">[3]</a> </sup> </sup> We included both fee-for-service (FFS) claims and managed care encounter records, which represent claims paid by managed care organizations and should generally follow the same reporting standards for billing and servicing providers. We excluded financial transaction records, supplemental payments, and &ldquo;other&rdquo; records that the state did not classify as being covered by either the Medicaid or CHIP programs. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-3\" id=\"footnote-ref-3\">[4]</a> </sup> </sup> <sup> &nbsp; </sup> We also excluded states from the analysis of each file if the number of header records in the TAF was low enough to be unusable. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-4\" id=\"footnote-ref-4\">[5]</a> </sup> </sup> <sup> &nbsp; </sup> For Illinois, we restricted our analysis to the original version of the claim and excluded all subsequent adjustment records in the state&rsquo;s TAF data. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-5\" id=\"footnote-ref-5\">[6]</a> </sup> </sup></p><p class=\"msword-table-title\"> Table 1. Crosswalk between file type, data element description, and TAF variable name</p><table aria-label=\"Table 1. Crosswalk between file type, data element description, and TAF variable name\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> File type </p> </th> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Data element description </p> </th> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Variable name </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> IP, LT, OT </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Billing provider </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> BLG_PRVDR_TYPE_CD </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> IP, LT, OT, RX </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Billing provider specialty code </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> BLG_PRVDR_SPCLTY_CD </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> IP, LT, OT, RX </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Billing provider state-reported taxonomy code </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> BLG_PRVDR_TXNMY_CD </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> IP, LT, OT </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Billing provider NPPES primary taxonomy code </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> BLG_PRVDR_NPPES_TXNMY_CD </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> OT </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Servicing provider type code </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> SRVCNG_PRVDR_TYPE_CD </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> OT </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Servicing provider specialty code </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> SRVCNG_PRVDR_SPCLTY_CD </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> OT </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Servicing provider state-reported taxonomy code </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> SRVCNG_PRVDR_TXNMY_CD </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> OT </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Servicing provider NPPES primary taxonomy code </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> SRVCNG_PRVDR_NPPES_TXNMY_CD </p> </td> </tr> </tbody></table><p class=\"msword-paragraph\"> The provider type code includes 57 different valid values, covering both facilities and professionals. As shown in Table 2, we grouped these values into those that are expected, unexpected, and unusable for billing providers for each of the three file types in which this data element is present (IP, LT, OT) and for servicing providers in the OT file.</p><p class=\"msword-paragraph\"> In the IP file, we would expect to see only general hospitals and Indian Health Service facilities as billing providers. In the LT file, we would expect to see nursing facilities, intermediate care facilities for individuals with intellectual or developmental disabilities, and psychiatric facilities as billing providers, as well as general hospitals in selected cases. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-6\" id=\"footnote-ref-6\">[7]</a> </sup> </sup> <sup class=\"msword-footnote-reference\"> &nbsp; </sup> In the OT file, we would expect to see a broad range of both facilities and professionals billing for and directly providing services.</p><p class=\"msword-paragraph\"> For all three files, we examined the &ldquo;all other&rdquo; code separately from the expected and unexpected categories. In some instances, use of the non-specific &ldquo;all other&rdquo; code may reflect the possibility that the provider is not represented in the list of valid provider type codes, which is the case for certain types of home- and community-based services (HCBS) and non-emergency medical transport providers. Although this code is valid and not considered an unexpected value in any file, it does not provide any information about the billing or servicing provider and thus renders the data element unusable for analysis.</p><p class=\"msword-table-title\"> Table 2. Classification of provider type codes, by file and provider field</p><table aria-label=\"Table 2. Classification of provider type codes, by file and provider field\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> File and provider field </p> </th> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Expected codes </p> </th> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Unusable codes (&ldquo;all other&rdquo; value) </p> </th> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Unexpected codes </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> IP&mdash;billing provider </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 42, 51 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 57 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> All other values </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> LT&mdash;billing provider </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 42, 43, 44, 45 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 57 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> All other values </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> OT&mdash;billing and servicing provider </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 01&minus;56 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 57 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> None </p> </td> </tr> </tbody></table><p class=\"msword-table-source\"> Source: A full list of values is available in the TAF Claims Codebook at&nbsp; <a aria-label=\"View the TAF Claims Codebook on the Chronic Conditions Data Warehouse Data Dictionaries page\" href=\"https://www2.ccwdata.org/web/guest/data-dictionaries\">https://www2.ccwdata.org/web/guest/data-dictionaries</a> . The provider type code values are identical across all three files.</p><p class=\"msword-paragraph\"> The provider specialty code includes 115 different valid values, covering both facilities and professionals. As shown in Table 3, we grouped these values into those that are expected and unexpected for each of the file types and provider fields. In the IP file, we would expect to see only general hospitals as billing providers. In the LT file, we would expect to see nursing facilities, intermediate care facilities for individuals with intellectual or developmental disabilities, and psychiatric facilities as billing providers, as well as general hospitals in selected cases. <sup> &nbsp; </sup> In the OT file, we would expect to see a broad range of both facilities and professionals billing for and directly providing services. In the RX file, we would expect to see pharmacies, medical supply companies, department stores, and grocery stores as billing providers. For all files and provider fields, we examined the &ldquo;all other&rdquo; codes (billing provider specialty code 87&mdash;All Other Suppliers) separately from the expected and unexpected categories. Although this code is valid and not considered an unexpected value in any file, it does not provide any information about the provider and thus renders the data element unusable for analysis.</p><p class=\"msword-table-title\"> Table 3. Classification of provider specialty codes, by file and provider field</p><table aria-label=\"Table 3. Classification of provider specialty codes, by file and provider field\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> File and provider field </p> </th> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Expected codes </p> </th> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Unusable codes (&ldquo;all other&rdquo; value) </p> </th> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Unexpected codes </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> IP&mdash;billing provider </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> A0 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 87 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> All other values except 88 and 99, which are treated as missing </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> LT&mdash;billing provider </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> A0, A1, A2, A3, B4 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 87 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> All other values except 88 and 99, which are treated as missing </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> OT&mdash;billing and servicing provider </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 1&minus;86, 89&minus;98, A0&minus;B5 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 87 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> All other values except 88 and 99, which are treated as missing </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> RX&mdash;billing provider </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 51&ndash;54, 58, 73, A5, A6, A9, B1, B3, B4 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 87 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> All other values except 88 and 99, which are treated as missing </p> </td> </tr> </tbody></table><p class=\"msword-table-source\"> Source: A full list of values is available in the TAF Claims Codebook at&nbsp; <a aria-label=\"View the TAF Claims Codebook on the Chronic Conditions Data Warehouse Data Dictionaries page\" href=\"https://www2.ccwdata.org/web/guest/data-dictionaries\">https://www2.ccwdata.org/web/guest/data-dictionaries</a> . The provider specialty code values are identical across all claims files.</p><p class=\"msword-paragraph\"> The state-reported billing provider taxonomy code is a 10-character alphanumeric code that identifies the provider&rsquo;s area of specialization. As shown in Table 4, we grouped these values into those that are expected and unexpected for each of the file types. In the IP file, we would expect to see inpatient hospitals as billing providers. In the LT files we would expect to see nursing facilities, intermediate care facility services for individuals with intellectual disabilities, mental health facility services, and independent (free-standing) psychiatric wings of acute care hospitals as billing providers. In the OT file, we would expect to see a broad range of both facilities and professionals billing for and directly providing services. In the RX file, we would expect to see pharmacies and other suppliers as billing providers.</p><p class=\"msword-paragraph\"> In addition to the state-reported provider taxonomy codes, IP, OT and LT files produced in 2022 and later years also include a constructed taxonomy variable for billing and servicing providers, the NPPES primary taxonomy code (*_NPPES_TXNMY_CD), that represents the provider&rsquo;s primary taxonomy information as reported in the National Plan and Provider Enumeration System (NPPES) based on the provider&rsquo;s National Provider Identifier. We used the same criteria as the state-reported taxonomy codes to determine expected and unexpected values for each file type.</p><p class=\"msword-table-title\"> Table 4. Classification of provider taxonomy codes, by file and provider field</p><table aria-label=\"Table 4. Classification of provider taxonomy codes, by file and provider field\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> File and provider field </p> </th> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Expected codes </p> </th> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Unexpected codes </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> IP&mdash;billing provider </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> First 2 digits of taxonomy code are 27 or 28 </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> All other values </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> LT&mdash;billing provider </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Taxonomy code begins with 283Q, 283X, 282E, 31, 32, 385H, or 281P </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> All other values </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> OT&mdash;billing and servicing provider </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> All valid taxonomy codes </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> None </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> RX&mdash;billing provider </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> First 2 digits of taxonomy code are 33, first 3 digits are 183, or 302R00000X <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-7\" id=\"footnote-ref-7\">[8]</a> </sup> </sup> </p> </td> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> All other values </p> </td> </tr> </tbody></table><p class=\"msword-table-source\"> Source: The health care provider taxonomy code set can be found at <a aria-label=\"View the 2019 Health Care Provider Taxonomy Code Set\" href=\"http://www.wpc-edi.com/reference/codelists/healthcare/health-care-provider-taxonomy-code-set/\">http://www.wpc-edi.com/reference/codelists/healthcare/health-care-provider-taxonomy-code-set/</a> . The provider taxonomy code values are identical across all claims files.</p><p class=\"msword-paragraph\"> We grouped states into categories of low, medium, and high concern about the usability of their data, based on the percentage of header records (or for servicing providers in the OT file, claim lines) that had an expected provider type, specialty, state-reported taxonomy code, or NPPES primary taxonomy code for the file and provider fields (Table 5).</p><p class=\"msword-paragraph\"> Because users of the OT file may be interested in professional or institutional (facility) claims, we conducted the DQ assessment separately for each of these claim types. Table 6 shows the methodology used to classify each claim header as a professional or institutional claim. Any claim that did not meet at least one of the criteria for a professional or institutional claim was considered unclassified and is not included in this analysis. Note that the servicing provider analyses were conducted at the claim line level, but the claims were classified as professional or institutional claims at the claim header level.</p><p class=\"msword-table-title\"> Table 5. Criteria for DQ assessment of provider type, specialty, and taxonomy code</p><table aria-label=\"Table 5. Criteria for DQ assessment of provider type, specialty, and taxonomy code\" class=\"dq-assessment-table\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Percentage of records with an expected provider type, specialty, state-reported taxonomy code, or NPPES primary taxonomy code </p> </th> <th class=\"msword-table-header-left dq-assessment-col\"> <p class=\"msword-table-header-left\"> DQ assessment </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &ge; 90 percent </p> </td> <td class=\"msword-table-text-left dq-assessment-col dq-level low\"> <p class=\"msword-table-text-left\"> Low concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 80 percent &le; x &lt; 90 percent </p> </td> <td class=\"msword-table-text-left dq-assessment-col dq-level medium\"> <p class=\"msword-table-text-left\"> Medium concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 50 percent &le; x &lt; 80 percent </p> </td> <td class=\"msword-table-text-left dq-assessment-col dq-level high\"> <p class=\"msword-table-text-left\"> High concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &lt; 50 percent </p> </td> <td class=\"msword-table-text-left dq-assessment-col dq-level unusable\"> <p class=\"msword-table-text-left\"> Unusable </p> </td> </tr> </tbody></table><p class=\"msword-table-title\"> Table 6. Classification of OT claim headers as professional or facility claims</p><table aria-label=\"Table 6. Classification of OT claim headers as professional or facility claims\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Claim category </p> </th> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Identification rules </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Professional </p> </td> <td> <p class=\"msword-table-text-left\"> The record must meet at least one of the following criteria: </p> <ul> <li class=\"msword-table-list-bullet\"> Has a valid place of service code on the header record and a missing or invalid revenue code on all line records </li> <li class=\"msword-table-list-bullet\"> Has a missing or invalid place of service code in the header record, a missing or invalid type of bill code in the header record, and a missing or invalid revenue code plus a valid procedure code in all line records </li> </ul> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Institutional </p> </td> <td> <p class=\"msword-table-text-left\"> The record must meet at least one of the following criteria: </p> <ul> <li class=\"msword-table-list-bullet\"> Has at least one line with a valid revenue code </li> <li class=\"msword-table-list-bullet\"> Has a valid type of bill code and a missing or invalid place of service code </li> </ul> </td> </tr> </tbody></table><p class=\"msword-header\"> Methods previously used to assess data quality</p><p> <a id=\"_Hlk71024897\"></a> Table 7 includes information about methods previously used to assess data quality and the data years and versions assessed using those methods. Each table record describes how the assessment methods for the listed data years and versions differ from current methods. Aside from those differences, the assessments for these data years and versions align with current methods. All data years and versions not listed in the table are assessed using current methods.</p><p class=\"msword-table-title\"> Table 7. Previously used methods and applicable data years and versions</p><table aria-label=\"Table 7. Previously used methods and applicable data years and versions\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Data year(s) and version(s) </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Description of difference(s) from current methods </p> </th> </tr> </thead> <tbody> <tr> <td> <ul> <li class=\"msword-table-list-bullet\"> 2014 Release 2 </li> <li class=\"msword-table-list-bullet\"> 2015 Release 2 </li> <li class=\"msword-table-list-bullet\"> 2016 Releases 1 and 2 </li> <li class=\"msword-table-list-bullet\"> 2017 Releases 1 and 2 </li> <li class=\"msword-table-list-bullet\"> 2018 Releases 1 and 2 </li> <li class=\"msword-table-list-bullet\"> 2019 Preliminary Release and Release 1 </li> </ul> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> The assessments of billing provider information for the IP, LT, and OT file are only based on the percentage of claims with an expected billing provider type code. Measures related to billing provider taxonomy code and billing provider specialty code are not calculated or included in the assessments. </li> <li class=\"msword-table-list-bullet\"> The assessment for billing provider information in the OT file is based on all OT claims, rather than having separate assessments for institutional and professional claims. </li> <li class=\"msword-table-list-bullet\"> The measures and assessment associated with the Billing Provider Taxonomy and Specialty - RX topic are not calculated. </li> <li class=\"msword-table-list-bullet\"> The measures and assessment associated with the Servicing Provider Type, Specialty, and Taxonomy - OT Professional topic are not calculated. </li> <li class=\"msword-table-list-bullet\"> The measures and assessment associated with the Servicing Provider Type, Specialty, and Taxonomy - OT Institutional topic are not calculated. </li> <li class=\"msword-table-list-bullet\"> Records with missing place of service, type of bill and revenue codes are not classified as professional claims, even if they have a valid procedure code on all line records. </li> </ul> </td> </tr> <tr> <td> <ul> <li class=\"msword-table-list-bullet\"> 2014 Release 2 </li> <li class=\"msword-table-list-bullet\"> 2015 Release 2 </li> <li class=\"msword-table-list-bullet\"> 2016 Releases 1 and 2 </li> <li class=\"msword-table-list-bullet\"> 2017 Releases 1 and 2 </li> <li class=\"msword-table-list-bullet\"> 2018 Releases 1 and 2 </li> <li class=\"msword-table-list-bullet\"> 2019 Preliminary Release and Release 1 </li> <li class=\"msword-table-list-bullet\"> 2020 Preliminary Release </li> </ul> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> Zero-filled revenue code values are considered valid when distinguishing between institutional and professional claims. </li> <li class=\"msword-table-list-bullet\"> Contextual measures of the percentage of records with a valid or expected NPPES primary taxonomy code are not calculated. </li> </ul> </td> </tr> <tr> <td> <ul> <li class=\"msword-table-list-bullet\"> 2014 Release 2 </li> <li class=\"msword-table-list-bullet\"> 2015 Release 2 </li> <li class=\"msword-table-list-bullet\"> 2016 Releases 1 and 2 </li> <li class=\"msword-table-list-bullet\"> 2017 Releases 1 and 2 </li> <li class=\"msword-table-list-bullet\"> 2018 Releases 1 and 2 </li> <li class=\"msword-table-list-bullet\"> 2019 Preliminary Release and Release 1 </li> <li class=\"msword-table-list-bullet\"> 2020 Preliminary Release and Release 1 </li> <li class=\"msword-table-list-bullet\"> 2021 Preliminary Release </li> </ul> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> NPPES primary taxonomy code is not included in the DQ assessment criteria for the billing (IP, LT, OT) and servicing provider (OT) topics. </li> </ul> </td> </tr> </tbody></table><ol> <li class=\"footnoteBody\" id=\"footnote-2\" value=\"3\"> <p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources page</a> , and a crosswalk of variable names can be found in the guide &ldquo;Production of the TAF Research Identifiable Files.&rdquo; </p> <p> <a href=\"#footnote-ref-2\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-3\" value=\"4\"> <p class=\"msword-footnote-text\"> We used claim type code (CLM_TYPE_CD) to determine which records to include and exclude in our analysis. Records included are those with a claim type code indicating FFS claims (values of 1 and A) and managed care encounters (3 and C). We excluded capitated payments (2 and B), supplemental payments (5 and E), and service-tracking claims (4 and D). We also used claim type code to exclude &ldquo;other&rdquo; records (values of U, V, W, X, and Y) that the state did not classify as either Medicaid or CHIP payment records. More information on supplemental payments and other claims can be found in the DQ Atlas single topic display for <a aria-label=\"View DQ Atlas single topic display for Non-Program (Other) Claims\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g7m61\">Non-Program (Other) Claims</a> . </p> <p> <a href=\"#footnote-ref-3\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-4\" value=\"5\"> <p class=\"msword-footnote-text\"> More information about the completeness of each state&rsquo;s TAF data can be found in the DQ Atlas single topic displays for <a aria-label=\"View DQ Atlas single topic display for Claims Volume - IP\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g4m45\">Claims Volume&mdash;IP</a> , <a aria-label=\"View DQ Atlas single topic display for Claims Volume - LT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g4m46\">Claims Volume&mdash;LT</a> , <a aria-label=\"View DQ Atlas single topic display for Claims Volume - OT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g4m47\">Claims Volume&mdash;OT</a> , and <a aria-label=\"View DQ Atlas single topic display for Claims Volume - RX\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g4m48\">Claims Volume&mdash;RX</a> . </p> <p> <a href=\"#footnote-ref-4\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-5\" value=\"6\"> <p class=\"msword-footnote-text\"> Because of limitations in its claims processing system, Illinois captures adjustments to original claims as incremental credits or debits rather than voiding the original claim and submitting a replacement record with the new payment amount. As a result, the version of a record with the latest adjudication date may not represent the final action claim, as it does in all other states. To ensure that the TAF correctly captures all expenditures reported by Illinois into T-MSIS, all service use records are included in the IP, OT, LT, and RX files. This approach means that in some cases, the TAF will include multiple versions of a single claim for Illinois, so including all records in an analysis will overcount service utilization. To ensure that utilization counts are correct, we restricted our analysis to the original claim from each claim family by selecting only those records where ADJSTMT_IND = 0 and ADJSTMT_CLM_NUM = null. For more information, see the guide, &ldquo;How to Use Illinois Claims Data,&rdquo; on ResDAC.org. </p> <p> <a href=\"#footnote-ref-5\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-6\" value=\"7\"> <p class=\"msword-footnote-text\"> General hospitals may provide sub-acute care through &ldquo;swing beds&rdquo; or other non-acute units within the hospital, and we would expect these claims to be found in the LT file rather than the IP file. </p> <p> <a href=\"#footnote-ref-6\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-7\" value=\"8\"> <p class=\"msword-footnote-text\"> At least one state (Florida) allows Health Maintenance Organizations (HMOs) to dispense pharmaceuticals to enrollees. Therefore, HMOs are included as an &ldquo;expected&rdquo; taxonomy for RX billing providers. </p> <p> <a href=\"#footnote-ref-7\">&uarr;</a> </p> </li></ol>", "footnotes": [{"number": 2, "content": "<li class=\"footnoteBody\" id=\"footnote-2\" value=\"3\"><p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources page</a> , and a crosswalk of variable names can be found in the guide \u201cProduction of the TAF Research Identifiable Files.\u201d </p><p><a href=\"#footnote-ref-2\">\u2191</a></p></li>"}, {"number": 3, "content": "<li class=\"footnoteBody\" id=\"footnote-3\" value=\"4\"><p class=\"msword-footnote-text\"> We used claim type code (CLM_TYPE_CD) to determine which records to include and exclude in our analysis. Records included are those with a claim type code indicating FFS claims (values of 1 and A) and managed care encounters (3 and C). We excluded capitated payments (2 and B), supplemental payments (5 and E), and service-tracking claims (4 and D). We also used claim type code to exclude \u201cother\u201d records (values of U, V, W, X, and Y) that the state did not classify as either Medicaid or CHIP payment records. More information on supplemental payments and other claims can be found in the DQ Atlas single topic display for <a aria-label=\"View DQ Atlas single topic display for Non-Program (Other) Claims\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g7m61\">Non-Program (Other) Claims</a> . </p><p><a href=\"#footnote-ref-3\">\u2191</a></p></li>"}, {"number": 4, "content": "<li class=\"footnoteBody\" id=\"footnote-4\" value=\"5\"><p class=\"msword-footnote-text\"> More information about the completeness of each state\u2019s TAF data can be found in the DQ Atlas single topic displays for <a aria-label=\"View DQ Atlas single topic display for Claims Volume - IP\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g4m45\">Claims Volume\u2014IP</a> , <a aria-label=\"View DQ Atlas single topic display for Claims Volume - LT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g4m46\">Claims Volume\u2014LT</a> , <a aria-label=\"View DQ Atlas single topic display for Claims Volume - OT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g4m47\">Claims Volume\u2014OT</a> , and <a aria-label=\"View DQ Atlas single topic display for Claims Volume - RX\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g4m48\">Claims Volume\u2014RX</a> . </p><p><a href=\"#footnote-ref-4\">\u2191</a></p></li>"}, {"number": 5, "content": "<li class=\"footnoteBody\" id=\"footnote-5\" value=\"6\"><p class=\"msword-footnote-text\"> Because of limitations in its claims processing system, Illinois captures adjustments to original claims as incremental credits or debits rather than voiding the original claim and submitting a replacement record with the new payment amount. As a result, the version of a record with the latest adjudication date may not represent the final action claim, as it does in all other states. To ensure that the TAF correctly captures all expenditures reported by Illinois into T-MSIS, all service use records are included in the IP, OT, LT, and RX files. This approach means that in some cases, the TAF will include multiple versions of a single claim for Illinois, so including all records in an analysis will overcount service utilization. To ensure that utilization counts are correct, we restricted our analysis to the original claim from each claim family by selecting only those records where ADJSTMT_IND = 0 and ADJSTMT_CLM_NUM = null. For more information, see the guide, \u201cHow to Use Illinois Claims Data,\u201d on ResDAC.org. </p><p><a href=\"#footnote-ref-5\">\u2191</a></p></li>"}, {"number": 6, "content": "<li class=\"footnoteBody\" id=\"footnote-6\" value=\"7\"><p class=\"msword-footnote-text\"> General hospitals may provide sub-acute care through \u201cswing beds\u201d or other non-acute units within the hospital, and we would expect these claims to be found in the LT file rather than the IP file. </p><p><a href=\"#footnote-ref-6\">\u2191</a></p></li>"}, {"number": 7, "content": "<li class=\"footnoteBody\" id=\"footnote-7\" value=\"8\"><p class=\"msword-footnote-text\"> At least one state (Florida) allows Health Maintenance Organizations (HMOs) to dispense pharmaceuticals to enrollees. Therefore, HMOs are included as an \u201cexpected\u201d taxonomy for RX billing providers. </p><p><a href=\"#footnote-ref-7\">\u2191</a></p></li>"}]}, "summary": {"content": "<p>The servicing provider type, specialty, and taxonomy codes allow TAF users to examine the characteristics of the individual practitioner who was responsible for or provided direct care to a Medicaid or CHIP beneficiary. This analysis examines the extent to which facility claims in the OT file have a servicing provider type, specialty, and taxonomy missing or coded with unexpected or unusable values.</p>", "footnotes": []}, "originalIssueBriefId": "5081", "relatedTopics": [{"measureId": 37, "measureName": "Billing Provider Type, Specialty, and Taxonomy - IP", "groupId": 6, "groupName": "Provider Information", "order": 0}, {"measureId": 38, "measureName": "Billing Provider Type, Specialty, and Taxonomy - LT", "groupId": 6, "groupName": "Provider Information", "order": 1}, {"measureId": 104, "measureName": "Billing Provider Type, Specialty, and Taxonomy - OT Professional", "groupId": 6, "groupName": "Provider Information", "order": 2}, {"measureId": 105, "measureName": "Billing Provider Type, Specialty, and Taxonomy - OT Institutional", "groupId": 6, "groupName": "Provider Information", "order": 3}, {"measureId": 103, "measureName": "Billing Provider Specialty and Taxonomy - RX", "groupId": 6, "groupName": "Provider Information", "order": 4}, {"measureId": 106, "measureName": "Servicing Provider Type, Specialty, and Taxonomy - OT Professional", "groupId": 6, "groupName": "Provider Information", "order": 5}]}
108
{"measureId": 108, "measureName": "Linking Claims to Beneficiaries", "groupId": 11, "groupName": "Linking Across Files", "pdfVersionLink": "downloads/background-and-methods/TAF-DQ-Link-Claims-Bene.pdf", "background": {"content": "<p class=\"msword-paragraph\"> The T-MSIS Analytic Files (TAF) consist of data on enrollment and service use for all individuals enrolled in Medicaid or in the Children&rsquo;s Health Insurance Program (CHIP). All service use records, including both fee-for-service (FFS) claims paid by the state Medicaid agency and managed care encounters paid by a Medicaid managed care plan, should link to a beneficiary eligibility record. The TAF Research Identifiable Files (RIF) include two beneficiary identifiers that can be used to make this linkage: (1) the state-assigned MSIS identifier (MSIS ID), which is in the eligibility and service use data that states submit into T-MSIS, and (2) the federally assigned beneficiary identifier (BENE ID). <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-2\" id=\"footnote-ref-2\">[1]</a> </sup> </sup> <sup> , </sup> <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-3\" id=\"footnote-ref-3\">[2]</a> </sup> </sup></p><p class=\"msword-paragraph\"> State Medicaid agencies and managed care plans should only pay for services delivered while an individual is enrolled in Medicaid or CHIP. Because the TAF excludes denied claims, <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-4\" id=\"footnote-ref-4\">[3]</a> </sup> </sup> all FFS claims and managed care encounter records in the inpatient (IP), other services (OT), long-term care (LT), and pharmacy (RX) files should link to an eligibility record in the TAF annual Demographic and Eligibility (DE) file that indicates the beneficiary was enrolled and eligible for services. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-5\" id=\"footnote-ref-5\">[4]</a> </sup> </sup></p><p class=\"msword-paragraph\"> Certain Medicaid policies could lead to predictable data quality errors in the enrollment start and end dates on eligibility records. When this occurs, service dates on paid claims may not match to enrollment dates on beneficiary eligibility records. For instance, Medicaid has a retroactive coverage policy that allows states to cover the costs of unpaid services provided up to three months before the beneficiary applied for coverage as long as the state can determine that the beneficiary would have been eligible during that period had he or she applied at that time. For a beneficiary who qualifies for retroactive eligibility, it is possible that a state will incorrectly code the start date of enrollment based on when an application was approved as opposed to when the coverage period started. If that occurs, the TAF may include paid claims with service dates in the three months before the beneficiary&rsquo;s enrollment date.</p><p class=\"msword-paragraph\"> Additionally, many states have adopted presumptive eligibility for certain low-income individuals, which allows providers such as hospitals to enroll patients into temporary Medicaid coverage for up to a month before the Medicaid agency makes a final eligibility determination. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-6\" id=\"footnote-ref-6\">[5]</a> </sup> </sup> <sup> , </sup> <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-7\" id=\"footnote-ref-7\">[6]</a> </sup> </sup> Although these individuals are enrolled in Medicaid during the period of presumptive eligibility, it is possible that a portion of them may later be determined ineligible for some or all of the months in which they received services; as a result, the state may submit their service use records but not their enrollment data.</p><p class=\"msword-paragraph\"> Sometimes, states may submit claims in T-MSIS with MSIS IDs for which they do not submit any corresponding eligibility information. There are a variety of reasons this could happen (such as administrative errors or an unintended consequence of presumptive eligibility policies), but only a small proportion of records in the DE file represent MSIS IDs for which the state submitted no eligibility information (less than 0.5 percent in the majority of states).</p><p class=\"msword-paragraph\"> This analysis examines the proportion of service use records in the TAF that can be linked to an eligibility record using the state-assigned MSIS ID. The ability to correctly link eligibility and service use records in the TAF is critical for analyses in which diagnoses, services, or expenditures must be attributed to specific individuals, such as counting the number of beneficiaries with certain health conditions, calculating quality measures, or calculating per-beneficiary costs for a specific subgroup of beneficiaries. Service use records that do not link to eligibility records indicate data quality issues with either the enrollment or the service use information reported by states.</p><ol> <li class=\"footnoteBody\" id=\"footnote-2\" value=\"1\"> <p class=\"msword-footnote-text\"> The BENE ID is created from the state-assigned MSIS ID and other person-specific variables (such as birth date and sex) by looking across records that have different state-assigned unique identifiers to determine whether they represent the same person. The BENE ID can be used to identify the same individual enrolled in Medicaid or CHIP in more than one state. It can also be used to link to the Medicare data for dually eligible beneficiaries. </p> <p> <a href=\"#footnote-ref-2\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-3\" value=\"2\"> <p class=\"msword-footnote-text\"> More information on the availability and quality of MSIS ID and BENE ID is available in the brief, \"Unique Beneficiary Identifiers in TAF,\" available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page </p> <p> <a href=\"#footnote-ref-3\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-4\" value=\"3\"> <p class=\"msword-footnote-text\"> TAF excludes denied header records and all the line records associated with it. However, it includes denied claim lines associated with non-denied header records. </p> <p> <a href=\"#footnote-ref-4\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-5\" value=\"4\"> <p class=\"msword-footnote-text\"> The DE file includes \"dummy\" records with beneficiary identification numbers that are observed on claims but were not reported by states in their eligibility data submissions. As a result, every service use record in the IP, LT, OT, and RX files will link to a DE record when using MSIS ID and state to make the linkage. However, these dummy records do not include any information regarding enrollment or beneficiary characteristics. </p> <p> <a href=\"#footnote-ref-5\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-6\" value=\"5\"> <p class=\"msword-footnote-text\"> Historically, presumptive eligibility policies allowed certain qualified providers to screen and temporarily enroll children and pregnant women into Medicaid or CHIP. Under the Affordable Care Act, states have the option to extend presumptive eligibility to cover low-income parents and other adults. For more information, see 42 CFR 435.11 (Options for Coverage of Special Groups under Presumptive Eligibility). </p> <p> <a href=\"#footnote-ref-6\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-7\" value=\"6\"> <p class=\"msword-footnote-text\"> A list of states that provide presumptive eligibility in Medicaid and/or CHIP can be found here: <a aria-label=\"View List of States that provide Presumptive Eligibility in Medicaid and CHIP\" href=\"https://www.kff.org/health-reform/state-indicator/presumptive-eligibility-in-medicaid-chip/?currentTimeframe=0&amp;sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D\">https://www.kff.org/health-reform/state-indicator/presumptive-eligibility-in-medicaid-chip/?currentTimeframe=0&amp;sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D</a> </p> <p> <a href=\"#footnote-ref-7\">&uarr;</a> </p> </li></ol>", "footnotes": [{"number": 2, "content": "<li class=\"footnoteBody\" id=\"footnote-2\" value=\"1\"><p class=\"msword-footnote-text\"> The BENE ID is created from the state-assigned MSIS ID and other person-specific variables (such as birth date and sex) by looking across records that have different state-assigned unique identifiers to determine whether they represent the same person. The BENE ID can be used to identify the same individual enrolled in Medicaid or CHIP in more than one state. It can also be used to link to the Medicare data for dually eligible beneficiaries. </p><p><a href=\"#footnote-ref-2\">\u2191</a></p></li>"}, {"number": 3, "content": "<li class=\"footnoteBody\" id=\"footnote-3\" value=\"2\"><p class=\"msword-footnote-text\"> More information on the availability and quality of MSIS ID and BENE ID is available in the brief, \"Unique Beneficiary Identifiers in TAF,\" available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page </p><p><a href=\"#footnote-ref-3\">\u2191</a></p></li>"}, {"number": 4, "content": "<li class=\"footnoteBody\" id=\"footnote-4\" value=\"3\"><p class=\"msword-footnote-text\"> TAF excludes denied header records and all the line records associated with it. However, it includes denied claim lines associated with non-denied header records. </p><p><a href=\"#footnote-ref-4\">\u2191</a></p></li>"}, {"number": 5, "content": "<li class=\"footnoteBody\" id=\"footnote-5\" value=\"4\"><p class=\"msword-footnote-text\"> The DE file includes \"dummy\" records with beneficiary identification numbers that are observed on claims but were not reported by states in their eligibility data submissions. As a result, every service use record in the IP, LT, OT, and RX files will link to a DE record when using MSIS ID and state to make the linkage. However, these dummy records do not include any information regarding enrollment or beneficiary characteristics. </p><p><a href=\"#footnote-ref-5\">\u2191</a></p></li>"}, {"number": 6, "content": "<li class=\"footnoteBody\" id=\"footnote-6\" value=\"5\"><p class=\"msword-footnote-text\"> Historically, presumptive eligibility policies allowed certain qualified providers to screen and temporarily enroll children and pregnant women into Medicaid or CHIP. Under the Affordable Care Act, states have the option to extend presumptive eligibility to cover low-income parents and other adults. For more information, see 42 CFR 435.11 (Options for Coverage of Special Groups under Presumptive Eligibility). </p><p><a href=\"#footnote-ref-6\">\u2191</a></p></li>"}, {"number": 7, "content": "<li class=\"footnoteBody\" id=\"footnote-7\" value=\"6\"><p class=\"msword-footnote-text\"> A list of states that provide presumptive eligibility in Medicaid and/or CHIP can be found here: <a aria-label=\"View List of States that provide Presumptive Eligibility in Medicaid and CHIP\" href=\"https://www.kff.org/health-reform/state-indicator/presumptive-eligibility-in-medicaid-chip/?currentTimeframe=0&amp;sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D\">https://www.kff.org/health-reform/state-indicator/presumptive-eligibility-in-medicaid-chip/?currentTimeframe=0&amp;sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D</a></p><p><a href=\"#footnote-ref-7\">\u2191</a></p></li>"}]}, "methods": {"content": "<p class=\"msword-paragraph\"> We used the claim type code (CLM_TYPE_CD) to select all header records <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-2\" id=\"footnote-ref-2\">[7]</a> </sup> </sup> classified as fee-for-service (FFS) claims or managed care encounters from the four TAF claim files. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-3\" id=\"footnote-ref-3\">[8]</a> </sup> </sup> <sup> , </sup> <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-4\" id=\"footnote-ref-4\">[9]</a> </sup> </sup> From the Demographic and Eligibility (DE) TAF, we selected all non-dummy records, which represent Medicaid and CHIP beneficiaries who the state indicated were enrolled at any time during the calendar year. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-5\" id=\"footnote-ref-5\">[10]</a> </sup> </sup></p><p class=\"msword-paragraph\"> We matched header records from the claims files to eligibility records by using the state-assigned beneficiary identifier (MSIS_IDENT_NUM) and the submitting state code (SUBMTG_STATE_CD). If a header record matched to a DE record that indicated that the person was enrolled during the month in which the service occurred, we counted it as matching to a beneficiary enrolled at the time of service (same-month match). <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-6\" id=\"footnote-ref-6\">[11]</a> </sup> </sup> <sup> , </sup> <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-7\" id=\"footnote-ref-7\">[12]</a> </sup> </sup></p><p class=\"msword-paragraph\"> We grouped states into categories of concern about the usability of their data, depending on the percentage of service records that do not link to an eligibility record in the same month of service (Table 1).</p><p class=\"msword-table-title\"> Table 1. Criteria for DQ assessment of the linkage of claims to beneficiaries</p><table aria-label=\"Table 1. Criteria for DQ assessment of the linkage of claims to beneficiaries\" class=\"dq-assessment-table\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Percentage of service use records that do not link to an eligibility record in the same month of service </p> </th> <th class=\"msword-table-header-center dq-assessment-col\"> <p class=\"msword-table-header-center\"> DQ assessment </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &le; 1 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level low\"> <p class=\"msword-table-text-centered\"> Low concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 1 percent &lt; x &le; 10 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level medium\"> <p class=\"msword-table-text-centered\"> Medium concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 10 percent &lt; x &le; 20 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level high\"> <p class=\"msword-table-text-centered\"> High concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &gt; 20 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level unusable\"> <p class=\"msword-table-text-centered\"> Unusable </p> </td> </tr> </tbody></table><ol> <li class=\"footnoteBody\" id=\"footnote-2\" value=\"7\"> <p class=\"msword-footnote-text\"> Header records summarize the service or the set of linked services provided to a beneficiary. Line records have more detailed information about the services provided. We used the header record for this analysis because the majority of studies in which claims data are used will be based on the summary information in the header record. </p> <p> <a href=\"#footnote-ref-2\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-3\" value=\"8\"> <p class=\"msword-footnote-text\"> We selected records with claim type code = 1, 3, A, C, U, or W. </p> <p> <a href=\"#footnote-ref-3\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-4\" value=\"9\"> <p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page, and a crosswalk of variable names can be found in the guide \"Production of the TAF Research Identifiable Files.\" </p> <p> <a href=\"#footnote-ref-4\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-5\" value=\"10\"> <p class=\"msword-footnote-text\"> We excluded the \"dummy\" records from the DE file that represent MSIS IDs present on claims but for which the state submitted no enrollment information. Dummy records can be identified as those with MISG_ELGBLTY_DATA_IND = 1. </p> <p> <a href=\"#footnote-ref-5\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-6\" value=\"11\"> <p class=\"msword-footnote-text\"> If it was available, we used the monthly CHIP code (CHIP_CD) to identify beneficiaries enrolled in Medicaid or CHIP that month (CHIP_CD values of 1&ndash;4). CHIP code 4 (Medicaid and S-CHIP) is a valid value for 2014 through 2017 TAF. If the CHIP code was missing, we considered the beneficiary as enrolled in the month only if the eligibility group variable (ELGBLTY_GRP_CD) was not missing. </p> <p> <a href=\"#footnote-ref-6\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-7\" value=\"12\"> <p class=\"msword-footnote-text\"> TAF claims data are organized by month and year of service. For IP and LT claims, the discharge date (or if that is missing, the service end date) is used to determine the month and year of the service. For OT claims, the service end date is used to determine the month and year of the service. If the service end date is missing, then the service start date is used, and if the start date is missing, then the most recent service end date from all the claim lines is used. For RX claims, the prescription fill date is used to determine the month and year of the service. </p> <p> <a href=\"#footnote-ref-7\">&uarr;</a> </p> </li></ol>", "footnotes": [{"number": 2, "content": "<li class=\"footnoteBody\" id=\"footnote-2\" value=\"7\"><p class=\"msword-footnote-text\"> Header records summarize the service or the set of linked services provided to a beneficiary. Line records have more detailed information about the services provided. We used the header record for this analysis because the majority of studies in which claims data are used will be based on the summary information in the header record. </p><p><a href=\"#footnote-ref-2\">\u2191</a></p></li>"}, {"number": 3, "content": "<li class=\"footnoteBody\" id=\"footnote-3\" value=\"8\"><p class=\"msword-footnote-text\"> We selected records with claim type code = 1, 3, A, C, U, or W. </p><p><a href=\"#footnote-ref-3\">\u2191</a></p></li>"}, {"number": 4, "content": "<li class=\"footnoteBody\" id=\"footnote-4\" value=\"9\"><p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page, and a crosswalk of variable names can be found in the guide \"Production of the TAF Research Identifiable Files.\" </p><p><a href=\"#footnote-ref-4\">\u2191</a></p></li>"}, {"number": 5, "content": "<li class=\"footnoteBody\" id=\"footnote-5\" value=\"10\"><p class=\"msword-footnote-text\"> We excluded the \"dummy\" records from the DE file that represent MSIS IDs present on claims but for which the state submitted no enrollment information. Dummy records can be identified as those with MISG_ELGBLTY_DATA_IND = 1. </p><p><a href=\"#footnote-ref-5\">\u2191</a></p></li>"}, {"number": 6, "content": "<li class=\"footnoteBody\" id=\"footnote-6\" value=\"11\"><p class=\"msword-footnote-text\"> If it was available, we used the monthly CHIP code (CHIP_CD) to identify beneficiaries enrolled in Medicaid or CHIP that month (CHIP_CD values of 1\u20134). CHIP code 4 (Medicaid and S-CHIP) is a valid value for 2014 through 2017 TAF. If the CHIP code was missing, we considered the beneficiary as enrolled in the month only if the eligibility group variable (ELGBLTY_GRP_CD) was not missing. </p><p><a href=\"#footnote-ref-6\">\u2191</a></p></li>"}, {"number": 7, "content": "<li class=\"footnoteBody\" id=\"footnote-7\" value=\"12\"><p class=\"msword-footnote-text\"> TAF claims data are organized by month and year of service. For IP and LT claims, the discharge date (or if that is missing, the service end date) is used to determine the month and year of the service. For OT claims, the service end date is used to determine the month and year of the service. If the service end date is missing, then the service start date is used, and if the start date is missing, then the most recent service end date from all the claim lines is used. For RX claims, the prescription fill date is used to determine the month and year of the service. </p><p><a href=\"#footnote-ref-7\">\u2191</a></p></li>"}]}, "summary": {"content": "<p>All service use records in the TAF claims files should link to a beneficiary using the unique identifier that states assign to each beneficiary, the MSIS ID. This analysis examines the proportion of service use records in the TAF that can be linked to an eligibility record using the MSIS ID.</p>", "footnotes": []}, "originalIssueBriefId": "3141", "relatedTopics": []}
109
{"measureId": 109, "measureName": "National Provider Identifier", "groupId": 6, "groupName": "Provider Information", "pdfVersionLink": "downloads/background-and-methods/TAF-DQ-APR-NPI.pdf", "background": {"content": "<p class=\"msword-paragraph\"> <a id=\"_Hlk30592933\"></a> The T-MSIS Analytic Files (TAF) Annual Provider File (APR) captures detailed information about each provider authorized by a state to provide services to its Medicaid and Children&rsquo;s Health Insurance Program (CHIP) beneficiaries, as well as providers whose approval is pending, denied, or has been terminated. Providers are included in the TAF APR regardless of whether or how often the provider billed the state for services. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-2\" id=\"footnote-ref-2\">[1]</a> </sup> </sup> A provider could be a facility, a group of practitioners, or an individual practitioner. The TAF APR includes more detailed information about those providers rendering or billing for services compared to the limited provider information found on the fee-for-service (FFS) and encounter records in the TAF claims files. For example, FFS and encounter records on the TAF inpatient (IP), long-term care (LT), and other services (OT) files include information on each claim about the billing, servicing, and rendering provider&rsquo;s taxonomy, specialty, and state-identified provider type. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-3\" id=\"footnote-ref-3\">[2]</a> </sup> </sup> The TAF APR, on the other hand, includes details about the characteristics, locations, taxonomies and classifications, affiliated groups, affiliated programs, licensing and accreditations, and&mdash;for facility providers&mdash;bed types for Medicaid- or CHIP-eligible providers, as well as other identifiers associated with the provider. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-4\" id=\"footnote-ref-4\">[3]</a> </sup> </sup></p><p class=\"msword-paragraph\"> Each TAF APR base file record includes two provider identifiers: (1) the National Provider Identifier (NPI), which is the unique, 10-digit identification number that the National Plan and Provider Enumeration System (NPPES) assigns to each Health Insurance Portability and Accountability Act (HIPAA)-covered health care provider; and (2) the state-assigned provider identifier used in the state&rsquo;s Medicaid Management Information System. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-5\" id=\"footnote-ref-5\">[4]</a> </sup> </sup> The state-assigned provider identifier, if accurately reported in the TAF APR records, can be used to link to most provider data elements on TAF claims records to examine beneficiary service use and related payments. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-6\" id=\"footnote-ref-6\">[5]</a> </sup> </sup> However, in the event these records do not link well on state-assigned provider identifiers, the NPI can be used as a secondary linking mechanism. In addition, because a provider can participate with more than one state Medicaid program, and therefore more than one TAF APR record may represent a given provider, the NPI is needed to de-duplicate providers for cross-state or national-level analyses. Also, certain provider data elements on the TAF claims files&mdash;those indicating the supervising provider, operating provider, directing provider, and home health provider on a claim (where applicable)&mdash;specify only the NPI as a provider identifier. TAF users interested in linking the APR to these provider fields on claims must do so using the NPI. The NPI can also be used to link to other non-TAF data sources. TAF users may be interested in the quality of the NPI in order to link to the publicly available NPPES NPI registry to obtain additional information about a provider&rsquo;s characteristics. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-7\" id=\"footnote-ref-7\">[6]</a> </sup> </sup></p><p class=\"msword-paragraph\"> States are required to report NPIs for all providers that have been assigned an NPI by the NPPES. Certain \"atypical\" providers - who are authorized to deliver services to Medicaid and CHIP beneficiaries, but do not provide \"health care\", as defined in HIPAA 45 C.F.R. 160.103 - are not eligible to receive an NPI. Therefore, we do not expect the NPI field to be populated for TAF APR records representing these providers. Among atypical providers that are reimbursed by Medicaid programs are those who offer taxi services, home and vehicle modifications, and respite services. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-8\" id=\"footnote-ref-8\">[7]</a> </sup> </sup> There is significant variation across state Medicaid programs in the prevalence of atypical providers and the ability of states to report these providers into T-MSIS. In some states, atypical providers may represent a sizeable proportion of all APR records, whereas in other states they represent a very small percentage. This data quality assessment examines the extent to which a provider&rsquo;s NPI is available on the APR records and can be matched to an active NPI on the NPPES NPI registry, regardless of whether they are an atypical provider. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-9\" id=\"footnote-ref-9\">[8]</a> </sup> </sup></p><ol> <li class=\"footnoteBody\" id=\"footnote-2\" value=\"1\"> <p class=\"msword-footnote-text\"> TAF APR records present unique combinations of submitting state and provider identifier. Because a provider can participate with more than one state Medicaid program, more than one TAF APR record may represent a given provider. </p> <p> <a href=\"#footnote-ref-2\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-3\" value=\"2\"> <p class=\"msword-footnote-text\"> FFS and encounter records on the RX file also include information on each claim about the billing provider&rsquo;s taxonomy and specialty. In addition to billing and servicing provider information, FFS and encounter records on the IP and LT files include information on each claim about the admitting provider&rsquo;s taxonomy, specialty, and state-identified provider type. </p> <p> <a href=\"#footnote-ref-3\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-4\" value=\"3\"> <p class=\"msword-footnote-text\"> The TAF APR consists of nine files. The TAF APR base file includes basic provider characteristics, and eight additional supplemental files provide more detailed information on the following topics: the provider&rsquo;s classifications (for example, taxonomy code), Medicaid and/or CHIP program enrollment, group affiliation, health plan and program affiliation, geographic location(s), licensing and accreditation, other provider identifiers, and bed type. Each record in the APR TAF base file represents a provider enrolled with the state&rsquo;s Medicaid or CHIP program. Each provider record on the base file may link to more than one record on each supplemental file. </p> <p> <a href=\"#footnote-ref-4\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-5\" value=\"4\"> <p class=\"msword-footnote-text\"> Centers for Medicare &amp; Medicaid Services (CMS). \"CMS Guidance: Reporting Provider Identifiers in T-MSIS. \" Baltimore, MD: CMS, January 2019. Available at <a aria-label=\"View CMS Guidance on Reporting Provider Identifiers in T-MSIS\" href=\"https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/?entry=50507\">https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/?entry=50507</a> . </p> <p> <a href=\"#footnote-ref-5\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-6\" value=\"5\"> <p class=\"msword-footnote-text\"> More information on how well the state-assigned provider identifiers in the TAF claims files link to the TAF APR can be found in the DQ Atlas single-topic displays for <a aria-label=\"View DQ Atlas single topic display for Linking Claims to Providers\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g6m92\">Linking Claims to Providers</a> . </p> <p> <a href=\"#footnote-ref-6\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-7\" value=\"6\"> <p class=\"msword-footnote-text\"> The NPPES NPI registry is available at: <a aria-label=\"View NPPES NPI Registry\" href=\"https://npiregistry.cms.hhs.gov/\">https://npiregistry.cms.hhs.gov/</a> . </p> <p> <a href=\"#footnote-ref-7\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-8\" value=\"7\"> <p class=\"msword-footnote-text\"> See Smith, Dennis G. SMDL #06-020. Letter to State Medicaid Directors, September 19, 2006. Available at: <a aria-label=\"View Letter to State Medicaid Directors (SMDL #06-020)\" href=\"https://www.medicaid.gov/Federal-Policy-Guidance/downloads/SMD091906b.pdf\">https://www.medicaid.gov/Federal-Policy-Guidance/downloads/SMD091906b.pdf</a> . Some providers of non-healthcare services may be eligible for an NPI, for example if the provider renders other services that qualify them as a healthcare provider (or has done so in the past). </p> <p> <a href=\"#footnote-ref-8\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-9\" value=\"8\"> <p class=\"msword-footnote-text\"> An active NPI is a provider identifier that is present on the NPPES NPI registry and is either (1) not flagged as being deactivated before the start of the calendar year, or (2) is flagged as being deactivated before the start of the calendar year but subsequently reactivated during that calendar year. An NPI may be deactivated because of a provider&rsquo;s retirement or death, disbandment of a provider entity, or in cases of identity theft or fraudulent use. </p> <p> <a href=\"#footnote-ref-9\">&uarr;</a> </p> </li></ol>", "footnotes": [{"number": 2, "content": "<li class=\"footnoteBody\" id=\"footnote-2\" value=\"1\"><p class=\"msword-footnote-text\"> TAF APR records present unique combinations of submitting state and provider identifier. Because a provider can participate with more than one state Medicaid program, more than one TAF APR record may represent a given provider. </p><p><a href=\"#footnote-ref-2\">\u2191</a></p></li>"}, {"number": 3, "content": "<li class=\"footnoteBody\" id=\"footnote-3\" value=\"2\"><p class=\"msword-footnote-text\"> FFS and encounter records on the RX file also include information on each claim about the billing provider\u2019s taxonomy and specialty. In addition to billing and servicing provider information, FFS and encounter records on the IP and LT files include information on each claim about the admitting provider\u2019s taxonomy, specialty, and state-identified provider type. </p><p><a href=\"#footnote-ref-3\">\u2191</a></p></li>"}, {"number": 4, "content": "<li class=\"footnoteBody\" id=\"footnote-4\" value=\"3\"><p class=\"msword-footnote-text\"> The TAF APR consists of nine files. The TAF APR base file includes basic provider characteristics, and eight additional supplemental files provide more detailed information on the following topics: the provider\u2019s classifications (for example, taxonomy code), Medicaid and/or CHIP program enrollment, group affiliation, health plan and program affiliation, geographic location(s), licensing and accreditation, other provider identifiers, and bed type. Each record in the APR TAF base file represents a provider enrolled with the state\u2019s Medicaid or CHIP program. Each provider record on the base file may link to more than one record on each supplemental file. </p><p><a href=\"#footnote-ref-4\">\u2191</a></p></li>"}, {"number": 5, "content": "<li class=\"footnoteBody\" id=\"footnote-5\" value=\"4\"><p class=\"msword-footnote-text\"> Centers for Medicare &amp; Medicaid Services (CMS). \"CMS Guidance: Reporting Provider Identifiers in T-MSIS. \" Baltimore, MD: CMS, January 2019. Available at <a aria-label=\"View CMS Guidance on Reporting Provider Identifiers in T-MSIS\" href=\"https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/?entry=50507\">https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/?entry=50507</a> . </p><p><a href=\"#footnote-ref-5\">\u2191</a></p></li>"}, {"number": 6, "content": "<li class=\"footnoteBody\" id=\"footnote-6\" value=\"5\"><p class=\"msword-footnote-text\"> More information on how well the state-assigned provider identifiers in the TAF claims files link to the TAF APR can be found in the DQ Atlas single-topic displays for <a aria-label=\"View DQ Atlas single topic display for Linking Claims to Providers\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g6m92\">Linking Claims to Providers</a> . </p><p><a href=\"#footnote-ref-6\">\u2191</a></p></li>"}, {"number": 7, "content": "<li class=\"footnoteBody\" id=\"footnote-7\" value=\"6\"><p class=\"msword-footnote-text\"> The NPPES NPI registry is available at: <a aria-label=\"View NPPES NPI Registry\" href=\"https://npiregistry.cms.hhs.gov/\">https://npiregistry.cms.hhs.gov/</a> . </p><p><a href=\"#footnote-ref-7\">\u2191</a></p></li>"}, {"number": 8, "content": "<li class=\"footnoteBody\" id=\"footnote-8\" value=\"7\"><p class=\"msword-footnote-text\"> See Smith, Dennis G. SMDL #06-020. Letter to State Medicaid Directors, September 19, 2006. Available at: <a aria-label=\"View Letter to State Medicaid Directors (SMDL #06-020)\" href=\"https://www.medicaid.gov/Federal-Policy-Guidance/downloads/SMD091906b.pdf\">https://www.medicaid.gov/Federal-Policy-Guidance/downloads/SMD091906b.pdf</a> . Some providers of non-healthcare services may be eligible for an NPI, for example if the provider renders other services that qualify them as a healthcare provider (or has done so in the past). </p><p><a href=\"#footnote-ref-8\">\u2191</a></p></li>"}, {"number": 9, "content": "<li class=\"footnoteBody\" id=\"footnote-9\" value=\"8\"><p class=\"msword-footnote-text\"> An active NPI is a provider identifier that is present on the NPPES NPI registry and is either (1) not flagged as being deactivated before the start of the calendar year, or (2) is flagged as being deactivated before the start of the calendar year but subsequently reactivated during that calendar year. An NPI may be deactivated because of a provider\u2019s retirement or death, disbandment of a provider entity, or in cases of identity theft or fraudulent use. </p><p><a href=\"#footnote-ref-9\">\u2191</a></p></li>"}]}, "methods": {"content": "<p class=\"msword-paragraph\"> We examined the extent to which NPIs are both available on the APR records and can be matched to an active NPI on the NPPES NPI registry. For each provider record on the TAF APR, up to two NPIs can be reported on the APR base file; these NPIs, plus any additional ones beyond the first two, are reported on the APR identifiers supplemental file. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-2\" id=\"footnote-ref-2\">[9]</a> </sup> </sup> However, only one NPI is expected to be active at any given time, and only a small percentage of providers will ever have more than one NPI. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-3\" id=\"footnote-ref-3\">[10]</a> </sup> </sup> For each submitting state, we calculated (1) the percentage of records with only missing or invalidly formatted NPI <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-4\" id=\"footnote-ref-4\">[11]</a> </sup> </sup> (that is, both NPI fields on the APR base file as well as any additional NPIs present on the identifiers supplemental file contain either a missing NPI value or an invalidly formatted NPI); (2) the percentage of records with a validly formatted identifier that does not match to an active NPI on the NPPES registry; <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-5\" id=\"footnote-ref-5\">[12]</a> </sup> </sup> and (3) the total percentage of APR records with a valid NPI, defined as identifiers that successfully match to an active NPI on the NPPES NPI registry. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-6\" id=\"footnote-ref-6\">[13]</a> </sup> </sup></p><p class=\"msword-paragraph\"> For additional context, we examined the percentage of APR records with more than one valid NPI reported. For the subset of APR records that do not have a valid NPI, we also examined the percentage of these records that represent atypical providers (and are therefore not expected to have an NPI).</p><p class=\"msword-table-title\"> Table 1. Criteria for DQ assessment of NPI in the TAF APR</p><table aria-label=\"Table 1. Criteria for DQ assessment of NPI in the TAF APR\" class=\"dq-assessment-table\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Percentage of APR records with a valid NPI </p> </th> <th class=\"msword-table-header-center dq-assessment-col\"> <p class=\"msword-table-header-center\"> DQ assessment </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &gt; 90 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level low\"> <p class=\"msword-table-text-centered\"> Low concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 80 percent &lt; x &le; 90 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level medium\"> <p class=\"msword-table-text-centered\"> Medium concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 40 percent &lt; x &le; 80 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level high\"> <p class=\"msword-table-text-centered\"> High concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &le; 40 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level unusable\"> <p class=\"msword-table-text-centered\"> Unusable </p> </td> </tr> </tbody></table><ol> <li class=\"footnoteBody\" id=\"footnote-2\" value=\"9\"> <p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page, and a crosswalk of variable names can be found in the guide \"Production of the TAF Research Identifiable Files.\" </p> <p> <a href=\"#footnote-ref-2\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-3\" value=\"10\"> <p class=\"msword-footnote-text\"> Centers for Medicare &amp; Medicaid Services (CMS). \"CMS Guidance: Reporting Provider Identifiers in T-MSIS.\" Baltimore, MD: CMS, January 2019. Available at <a aria-label=\"View CMS Guidance on Reporting Provider Identifiers in T-MSIS\" href=\"https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/?entry=50507\">https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/?entry=50507</a> . </p> <p> <a href=\"#footnote-ref-3\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-4\" value=\"11\"> <p class=\"msword-footnote-text\"> An invalidly formatted NPI is one that does not meet all of the following criteria: (1) the NPI is 10-digit numeric, (2) the first digit of the NPI is a \"1\" or a \"2\" and (3) the NPI&rsquo;s 10th \"check\" digit is valid according to the Luhn formula. More information is available at <a aria-label=\"View Requirements for National Provider Identifier (NPI) and NPI Check Digit\" href=\"https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/Downloads/NPIcheckdigit.pdf\">https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/Downloads/NPIcheckdigit.pdf</a> . </p> <p> <a href=\"#footnote-ref-4\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-5\" value=\"12\"> <p class=\"msword-footnote-text\"> For this data quality assessment, identifiers that did not match to an active NPI on the NPPES registry include both (1) identifiers not present on the NPPES NPI registry and (2) identifiers flagged on the NPPES as being deactivated before the start of the calendar year (and not subsequently reactivated during that calendar year). </p> <p> <a href=\"#footnote-ref-5\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-6\" value=\"13\"> <p class=\"msword-footnote-text\"> APR records representing atypical providers were identified by linking APR base file records to the APR taxonomy supplemental file records. Providers that met both of the following criteria were counted as atypical provider: (1) the provider had one or more taxonomy, specialty, provider type, or authorized category of service codes applicable to atypical providers, and (2) the provider did not have one or more additional taxonomy, specialty, provider type, or authorized category of service codes applicable to HIPPA-defined health care providers (which would qualify for an NPI). </p> <p> <a href=\"#footnote-ref-6\">&uarr;</a> </p> </li></ol>", "footnotes": [{"number": 2, "content": "<li class=\"footnoteBody\" id=\"footnote-2\" value=\"9\"><p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page, and a crosswalk of variable names can be found in the guide \"Production of the TAF Research Identifiable Files.\" </p><p><a href=\"#footnote-ref-2\">\u2191</a></p></li>"}, {"number": 3, "content": "<li class=\"footnoteBody\" id=\"footnote-3\" value=\"10\"><p class=\"msword-footnote-text\"> Centers for Medicare &amp; Medicaid Services (CMS). \"CMS Guidance: Reporting Provider Identifiers in T-MSIS.\" Baltimore, MD: CMS, January 2019. Available at <a aria-label=\"View CMS Guidance on Reporting Provider Identifiers in T-MSIS\" href=\"https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/?entry=50507\">https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/?entry=50507</a> . </p><p><a href=\"#footnote-ref-3\">\u2191</a></p></li>"}, {"number": 4, "content": "<li class=\"footnoteBody\" id=\"footnote-4\" value=\"11\"><p class=\"msword-footnote-text\"> An invalidly formatted NPI is one that does not meet all of the following criteria: (1) the NPI is 10-digit numeric, (2) the first digit of the NPI is a \"1\" or a \"2\" and (3) the NPI\u2019s 10th \"check\" digit is valid according to the Luhn formula. More information is available at <a aria-label=\"View Requirements for National Provider Identifier (NPI) and NPI Check Digit\" href=\"https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/Downloads/NPIcheckdigit.pdf\">https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/Downloads/NPIcheckdigit.pdf</a> . </p><p><a href=\"#footnote-ref-4\">\u2191</a></p></li>"}, {"number": 5, "content": "<li class=\"footnoteBody\" id=\"footnote-5\" value=\"12\"><p class=\"msword-footnote-text\"> For this data quality assessment, identifiers that did not match to an active NPI on the NPPES registry include both (1) identifiers not present on the NPPES NPI registry and (2) identifiers flagged on the NPPES as being deactivated before the start of the calendar year (and not subsequently reactivated during that calendar year). </p><p><a href=\"#footnote-ref-5\">\u2191</a></p></li>"}, {"number": 6, "content": "<li class=\"footnoteBody\" id=\"footnote-6\" value=\"13\"><p class=\"msword-footnote-text\"> APR records representing atypical providers were identified by linking APR base file records to the APR taxonomy supplemental file records. Providers that met both of the following criteria were counted as atypical provider: (1) the provider had one or more taxonomy, specialty, provider type, or authorized category of service codes applicable to atypical providers, and (2) the provider did not have one or more additional taxonomy, specialty, provider type, or authorized category of service codes applicable to HIPPA-defined health care providers (which would qualify for an NPI). </p><p><a href=\"#footnote-ref-6\">\u2191</a></p></li>"}]}, "summary": {"content": "<p>The TAF Annual Provider File (APR) contains detailed information about each provider authorized to deliver services to Medicaid and CHIP beneficiaries at any point during the calendar year. Two provider identifiers are available on the TAF APR: the National Provider Identifier (NPI) and the state-assigned provider identifier used in the state's claims processing system. This data quality assessment examines the extent to which the TAF APR records include a valid NPI. </p>", "footnotes": []}, "originalIssueBriefId": "9051", "relatedTopics": []}
110
{"measureId": 110, "measureName": "Linking Expenditures to Beneficiaries", "groupId": 11, "groupName": "Linking Across Files", "pdfVersionLink": "downloads/background-and-methods/TAF-DQ-Link-Bene-Expenditures.pdf", "background": {"content": "<p class=\"msword-paragraph\"> The T-MSIS Analytic Files (TAF) consist of enrollment data in the eligibility file and spending data in the claims files for all individuals enrolled in Medicaid or in the Children&rsquo;s Health Insurance Program (CHIP). The TAF Research Identifiable Files (RIF) include two beneficiary identifiers that can be used to link expenditures to eligibility records: (1) the state-assigned MSIS identifier (MSIS ID), which is in the eligibility and service use data that states submit into T-MSIS, and (2) the federally assigned beneficiary identifier (BENE ID). <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-2\" id=\"footnote-ref-2\">[1]</a> </sup> </sup> <sup class=\"msword-footnote-reference\"> , </sup> <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-3\" id=\"footnote-ref-3\">[2]</a> </sup> </sup></p><p class=\"msword-paragraph\"> States can make Medicaid and CHIP payments on behalf of specific beneficiaries or in bulk for covered services using one of the following types of records: <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-4\" id=\"footnote-ref-4\">[3]</a> </sup> </sup></p><p class=\"msword-paragraph\"> <strong> Fee-for-service (FFS) claims </strong> , which represent payments to medical providers made directly by the state Medicaid or CHIP agency. These claims should correspond to specific individuals and services.</p><p class=\"msword-paragraph\"> <strong> Capitation payment records </strong> , which reflect a set per member per month (PMPM) rate paid by the state Medicaid or CHIP agency to a managed care organization (MCO), prepaid health plan (PHP), or primary care provider. These records should correspond to specific individuals. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-5\" id=\"footnote-ref-5\">[4]</a> </sup> </sup></p><p class=\"msword-paragraph\"> <strong> Supplemental payment records </strong> , which represent payments made in addition to a capitation payment or negotiated rate; they should correspond to specific individuals but not always to specific services.</p><p class=\"msword-paragraph\"> <strong> Service tracking claims </strong> , which represent lump-sum payments made for services that cannot be attributed to a specific beneficiary, such as disproportionate share hospital (DSH) payments, payments to providers made under the Upper Payment Limit demonstration, or aggregate payments to transportation providers. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-6\" id=\"footnote-ref-6\">[5]</a> </sup> </sup> Some states report capitation payments covering a group of individuals as service tracking claims.</p><p class=\"msword-paragraph\"> All FFS expenditures, PMPM expenditures on capitation claims, and supplemental payments in the inpatient (IP), other services (OT), long-term care (LT), and pharmacy (RX) files should link to an eligibility record in the TAF annual Demographic and Eligibility (DE) file that indicates the beneficiary was enrolled and eligible for services. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-7\" id=\"footnote-ref-7\">[6]</a> </sup> </sup> Non-claim based financial transactions reported in T-MSIS, which are most often found on service tracking claims, are not expected to link to beneficiaries but are helpful to include in this analysis so that TAF users can see the proportion of overall expenditures that can be linked to individual beneficiaries.</p><p class=\"msword-paragraph\"> Some circumstances might generate administrative data errors that cause a mismatch between service dates on paid claims and enrollment dates on beneficiary eligibility records. For instance, many states have adopted retroactive coverage or presumptive eligibility policies that allow them to cover costs of unpaid services for a certain amount of time before a beneficiary&rsquo;s final eligibility determination. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-8\" id=\"footnote-ref-8\">[7]</a> </sup> </sup> <sup class=\"msword-footnote-reference\"> , </sup> <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-9\" id=\"footnote-ref-9\">[8]</a> </sup> </sup> For beneficiaries affected by these policies, a state might incorrectly code the start date of enrollment based on the date an application was approved rather than the date the coverage period started, or a state might submit an individual&rsquo;s service use records but not their enrollment data.</p><p class=\"msword-paragraph\"> Because TAF claims records only include non-void, non-denied final action claims, nearly all FFS claims should have a positive total Medicaid paid amount. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-10\" id=\"footnote-ref-10\">[9]</a> </sup> </sup> <sup class=\"msword-footnote-reference\"> , </sup> <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-11\" id=\"footnote-ref-11\">[10]</a> </sup> </sup> In contrast, states may report negative payment values on non-claim-based financial transaction records, which include capitated payment records, service tracking claims, and supplemental payment records. A negative payment amount on a capitated payment record typically reflects a rate adjustment or corrections for beneficiaries who moved out of the state or died. A negative payment amount on a service tracking claim or supplemental payment record typically reflects an adjustment to the original payment amount. TAF users should be able to sum positive and negative payments across all relevant records to obtain beneficiary-level net expenditures for a particular time period or service type. If a state properly assigns valid beneficiary identifiers to records with positive payment values but reports adjustments or claw-backs as lump sums that cannot be linked to individual beneficiaries, TAF users will not be able to accurately calculate the net expenditures associated with each individual.</p><p class=\"msword-paragraph\"> To account for both positive and negative payment amounts, this analysis examines the absolute value of expenditures in TAF that can be linked to an eligibility record using the MSIS ID. States with a high proportion of expenditures that do not link to eligibility records might have data quality issues with their enrollment or payment information or might rely heavily on lump sum payments for Medicaid program operations. Both options limit the usability of TAF for beneficiary-level expenditure analyses.</p><p class=\"msword-paragraph\"></p><ol> <li class=\"footnoteBody\" id=\"footnote-2\" value=\"1\"> <p class=\"msword-footnote-text\"> The BENE ID is created from the state-assigned MSIS ID and other person-specific variables (such as birth date and sex) by looking across records that have different state-assigned unique identifiers to determine whether they represent the same person. The BENE ID can be used to identify the same individual enrolled in Medicaid or CHIP in more than one state. It can also be used to link to the Medicare data for dually eligible beneficiaries. </p> <p> <a href=\"#footnote-ref-2\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-3\" value=\"2\"> <p class=\"msword-footnote-text\"> More information on the availability and quality of MSIS ID and BENE ID is available in the data quality brief, &ldquo;Unique Beneficiary Identifiers in TAF,&rdquo; which can be found on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page </p> <p> <a href=\"#footnote-ref-3\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-4\" value=\"3\"> <p class=\"msword-footnote-text\"> Payments on managed care encounter records reflect payments made by MCOs or PHPs to providers for services rendered to covered beneficiaries and are therefore not included in this analysis. </p> <p> <a href=\"#footnote-ref-4\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-5\" value=\"4\"> <p class=\"msword-footnote-text\"> Capitation payments reported on service tracking claims cannot be linked to a specific beneficiary. All other monthly beneficiary payments can be linked to a specific beneficiary. </p> <p> <a href=\"#footnote-ref-5\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-6\" value=\"5\"> <p class=\"msword-footnote-text\"> Service tracking claims are excluded from 2014&ndash;2016 TAF RIF Releases 1 and 2 and 2017&ndash;2018 TAF RIF Release 1. </p> <p> <a href=\"#footnote-ref-6\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-7\" value=\"6\"> <p class=\"msword-footnote-text\"> The DE file includes &ldquo;dummy&rdquo; records with beneficiary identification numbers that are observed on claims but were not reported by states in their eligibility data submissions. As a result, every service use record in the IP, LT, OT, and RX files will link to a DE record when using MSIS ID and state to make the linkage. However, these dummy records do not include information on enrollment or beneficiary characteristics. </p> <p> <a href=\"#footnote-ref-7\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-8\" value=\"7\"> <p class=\"msword-footnote-text\"> Historically, presumptive eligibility policies allowed certain qualified providers to screen and temporarily enroll children and pregnant women into Medicaid or CHIP. Under the Affordable Care Act, states have the option to extend presumptive eligibility to cover low-income parents and other adults. <a id=\"_Hlk92457115\"></a> For more information, see 42 CFR 435.11 (Options for Coverage of Special Groups under Presumptive Eligibility). </p> <p> <a href=\"#footnote-ref-8\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-9\" value=\"8\"> <p class=\"msword-footnote-text\"> A list of states that provide presumptive eligibility in Medicaid and/or CHIP is available at <a aria-label=\"View List of States that provide Presumptive Eligibility in Medicaid and CHIP\" href=\"https://www.kff.org/health-reform/state-indicator/presumptive-eligibility-in-medicaid-chip/?currentTimeframe=0&amp;sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D\">https://www.kff.org/health-reform/state-indicator/presumptive-eligibility-in-medicaid-chip/?currentTimeframe=0&amp;sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D</a> . </p> <p> <a href=\"#footnote-ref-9\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-10\" value=\"9\"> <p class=\"msword-footnote-text\"> There are a few situations in which FFS claims are not expected to have a positive payment amount, including (1) claims for which Medicare or another liable third party already paid the full Medicaid allowable amount and (2) claims that are not paid on an FFS basis despite being processed at the individual claim level. </p> <p> <a href=\"#footnote-ref-10\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-11\" value=\"10\"> <p class=\"msword-footnote-text\"> It is not unusual for FFS claims in Illinois to have negative payment amounts due to the state&rsquo;s approach to processing claims. Instead of adjusting original claims through void and resubmission records, Illinois submits marginal adjustments to the original claim. </p> <p> <a href=\"#footnote-ref-11\">&uarr;</a> </p> </li></ol>", "footnotes": [{"number": 2, "content": "<li class=\"footnoteBody\" id=\"footnote-2\" value=\"1\"><p class=\"msword-footnote-text\"> The BENE ID is created from the state-assigned MSIS ID and other person-specific variables (such as birth date and sex) by looking across records that have different state-assigned unique identifiers to determine whether they represent the same person. The BENE ID can be used to identify the same individual enrolled in Medicaid or CHIP in more than one state. It can also be used to link to the Medicare data for dually eligible beneficiaries. </p><p><a href=\"#footnote-ref-2\">\u2191</a></p></li>"}, {"number": 3, "content": "<li class=\"footnoteBody\" id=\"footnote-3\" value=\"2\"><p class=\"msword-footnote-text\"> More information on the availability and quality of MSIS ID and BENE ID is available in the data quality brief, \u201cUnique Beneficiary Identifiers in TAF,\u201d which can be found on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page </p><p><a href=\"#footnote-ref-3\">\u2191</a></p></li>"}, {"number": 4, "content": "<li class=\"footnoteBody\" id=\"footnote-4\" value=\"3\"><p class=\"msword-footnote-text\"> Payments on managed care encounter records reflect payments made by MCOs or PHPs to providers for services rendered to covered beneficiaries and are therefore not included in this analysis. </p><p><a href=\"#footnote-ref-4\">\u2191</a></p></li>"}, {"number": 5, "content": "<li class=\"footnoteBody\" id=\"footnote-5\" value=\"4\"><p class=\"msword-footnote-text\"> Capitation payments reported on service tracking claims cannot be linked to a specific beneficiary. All other monthly beneficiary payments can be linked to a specific beneficiary. </p><p><a href=\"#footnote-ref-5\">\u2191</a></p></li>"}, {"number": 6, "content": "<li class=\"footnoteBody\" id=\"footnote-6\" value=\"5\"><p class=\"msword-footnote-text\"> Service tracking claims are excluded from 2014\u20132016 TAF RIF Releases 1 and 2 and 2017\u20132018 TAF RIF Release 1. </p><p><a href=\"#footnote-ref-6\">\u2191</a></p></li>"}, {"number": 7, "content": "<li class=\"footnoteBody\" id=\"footnote-7\" value=\"6\"><p class=\"msword-footnote-text\"> The DE file includes \u201cdummy\u201d records with beneficiary identification numbers that are observed on claims but were not reported by states in their eligibility data submissions. As a result, every service use record in the IP, LT, OT, and RX files will link to a DE record when using MSIS ID and state to make the linkage. However, these dummy records do not include information on enrollment or beneficiary characteristics. </p><p><a href=\"#footnote-ref-7\">\u2191</a></p></li>"}, {"number": 8, "content": "<li class=\"footnoteBody\" id=\"footnote-8\" value=\"7\"><p class=\"msword-footnote-text\"> Historically, presumptive eligibility policies allowed certain qualified providers to screen and temporarily enroll children and pregnant women into Medicaid or CHIP. Under the Affordable Care Act, states have the option to extend presumptive eligibility to cover low-income parents and other adults. <a id=\"_Hlk92457115\"></a> For more information, see 42 CFR 435.11 (Options for Coverage of Special Groups under Presumptive Eligibility). </p><p><a href=\"#footnote-ref-8\">\u2191</a></p></li>"}, {"number": 9, "content": "<li class=\"footnoteBody\" id=\"footnote-9\" value=\"8\"><p class=\"msword-footnote-text\"> A list of states that provide presumptive eligibility in Medicaid and/or CHIP is available at <a aria-label=\"View List of States that provide Presumptive Eligibility in Medicaid and CHIP\" href=\"https://www.kff.org/health-reform/state-indicator/presumptive-eligibility-in-medicaid-chip/?currentTimeframe=0&amp;sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D\">https://www.kff.org/health-reform/state-indicator/presumptive-eligibility-in-medicaid-chip/?currentTimeframe=0&amp;sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D</a> . </p><p><a href=\"#footnote-ref-9\">\u2191</a></p></li>"}, {"number": 10, "content": "<li class=\"footnoteBody\" id=\"footnote-10\" value=\"9\"><p class=\"msword-footnote-text\"> There are a few situations in which FFS claims are not expected to have a positive payment amount, including (1) claims for which Medicare or another liable third party already paid the full Medicaid allowable amount and (2) claims that are not paid on an FFS basis despite being processed at the individual claim level. </p><p><a href=\"#footnote-ref-10\">\u2191</a></p></li>"}, {"number": 11, "content": "<li class=\"footnoteBody\" id=\"footnote-11\" value=\"10\"><p class=\"msword-footnote-text\"> It is not unusual for FFS claims in Illinois to have negative payment amounts due to the state\u2019s approach to processing claims. Instead of adjusting original claims through void and resubmission records, Illinois submits marginal adjustments to the original claim. </p><p><a href=\"#footnote-ref-11\">\u2191</a></p></li>"}]}, "methods": {"content": "<p class=\"msword-callout\"> The following describes current methods used to assess data quality. Information about methods previously used to assess data quality can be found at the bottom of this section.</p><p class=\"msword-paragraph\"> We used the claim type code (CLM_TYPE_CD) to select all header records classified as FFS claims, capitated payment records, supplemental payment records, or service tracking claims from the four TAF claim files. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-2\" id=\"footnote-ref-2\">[11]</a> </sup> </sup> <sup class=\"msword-footnote-reference\"> , </sup> <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-3\" id=\"footnote-ref-3\">[12]</a> </sup> </sup> <sup class=\"msword-footnote-reference\"> , </sup> <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-4\" id=\"footnote-ref-4\">[13]</a> </sup> </sup> From the DE TAF, we selected all non-dummy records, which represent Medicaid and CHIP beneficiaries who the state indicated were enrolled at any time during the calendar year. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-5\" id=\"footnote-ref-5\">[14]</a> </sup> </sup></p><p class=\"msword-paragraph\"> We matched header records from the claims files to eligibility records by using the state-assigned beneficiary identifier (MSIS_IDENT_NUM) and the submitting state code (SUBMTG_STATE_CD). If a header record matched to a DE record that indicated that the person was enrolled during the month in which the service occurred, we counted it as matching to a beneficiary enrolled at the time of service (same-month match). <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-6\" id=\"footnote-ref-6\">[15]</a> </sup> </sup> <sup class=\"msword-footnote-reference\"> , </sup> <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-7\" id=\"footnote-ref-7\">[16]</a> </sup> </sup> We also calculated whether a header record matched a beneficiary enrolled at any time in the year of service to understand whether administrative errors found at the monthly level (such as those driven by retroactive and presumptive eligibility policies) affected linkage rates.</p><p class=\"msword-paragraph\"> We tabulated expenditures on FFS, capitated payment, and supplemental payment header records (those with claim type code = 1, 2, 5, A, B, or E) using the absolute value of the total Medicaid paid amount (TOT_MDCD_PD_AMT). We tabulated expenditures on service tracking claims (those with claim type code = 4 or D) using the absolute value of either the DSH payment amount (MDCD_DSH_PD_AMT), service tracking payment amount (SRVC_TRKNG_PYMT_AMT), or total Medicaid paid amount to tabulate expenditures. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-8\" id=\"footnote-ref-8\">[17]</a> </sup> </sup> <sup class=\"msword-footnote-reference\"> , </sup> <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-9\" id=\"footnote-ref-9\">[18]</a> </sup> </sup> <sup class=\"msword-footnote-reference\"> , </sup> <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-10\" id=\"footnote-ref-10\">[19]</a> </sup> </sup></p><p class=\"msword-paragraph\"> We grouped states into categories of concern about the usability of their data, depending on the percentage of the absolute value of expenditures that do not link to an eligibility record in the same month of service (Table 1).</p><p class=\"msword-table-title\"> Table 1. <a id=\"_Hlk34816350\"></a> Criteria for DQ assessment of the linkage of expenditures to beneficiaries</p><table aria-label=\"Table 1. Criteria for DQ assessment of the linkage of expenditures to beneficiaries\" class=\"dq-assessment-table\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> <a id=\"_Hlk90410438\"></a> Percentage of the absolute value of expenditures that do not link to an eligibility record in the same month of service </p> </th> <th class=\"msword-table-header-center dq-assessment-col\"> <p class=\"msword-table-header-center\"> DQ assessment </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &le; 15 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level low\"> <p class=\"msword-table-text-centered\"> Low concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 15 percent &lt; x &le; 30 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level medium\"> <p class=\"msword-table-text-centered\"> Medium concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 30 percent &lt; x &le; 50 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level high\"> <p class=\"msword-table-text-centered\"> High concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &gt; 50 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level unusable\"> <p class=\"msword-table-text-centered\"> Unusable </p> </td> </tr> </tbody></table><p class=\"msword-paragraph\"> To provide TAF users with additional detail about whether certain payment types are more or less likely to link to individual beneficiaries, we used the federally assigned service category (FED_SRVC_CTGRY_CD) to differentiate between FFS expenditures (payments that are for a specific service) and PMPM expenditures (non-claims-based financial transactions representing premiums or monthly fees). <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-11\" id=\"footnote-ref-11\">[20]</a> </sup> </sup> We tabulated FFS expenditures among records where the federally assigned service category is 21&ndash;28, 31&ndash;38, or 41. We tabulated PMPM expenditures among records where the federally assigned service category is 11 or 12. We separately list the proportion of FFS expenditures and PMPM expenditures that can be linked to eligibility records as contextual information in the table view for this topic.</p><p class=\"msword-header\"> Methods previously used to assess data quality</p><p> <a id=\"_Hlk71024897\"></a> Table 2 includes information about methods previously used to assess data quality and the data years and versions assessed using those methods. Each table record describes how the assessment methods for the listed data years and versions differ from current methods. Aside from those differences, the assessments for these data years and versions align with current methods. All data years and versions not listed in the table are assessed using current methods.</p><p class=\"msword-table-title\"> Table 2. Previously used methods and applicable data years and versions</p><table aria-label=\"Table 2. Previously used methods and applicable data years and versions\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Data year(s) and version(s) </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Description of difference(s) from current methods </p> </th> </tr> </thead> <tbody> <tr> <td> <ul> <li class=\"msword-table-list-bullet\"> 2020 Release 1 </li> <li class=\"msword-table-list-bullet\"> 2021 Preliminary Release and Release 1 </li> <li class=\"msword-table-list-bullet\"> 2022 Preliminary Release </li> </ul> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> For DQ assessment criteria, Low concern threshold is set at &le;10%, Medium concern threshold is set between 10% and 20%, and High concern threshold is set between 20% and 50%. </li> </ul> </td> </tr> </tbody></table><ol> <li class=\"footnoteBody\" id=\"footnote-2\" value=\"11\"> <p class=\"msword-footnote-text\"> Header records summarize the service or the set of linked services provided to a beneficiary. Line records have more detailed information about the services provided. We used the header record for this analysis because most studies in which claims data are used will be based on the summary information in the header record. </p> <p> <a href=\"#footnote-ref-2\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-3\" value=\"12\"> <p class=\"msword-footnote-text\"> We selected records with claim type code = 1, 2, 4, 5, A, B, D, or E. </p> <p> <a href=\"#footnote-ref-3\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-4\" value=\"13\"> <p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources page</a> , and a crosswalk of variable names can be found in the guide &ldquo;Production of the TAF Research Identifiable Files.&rdquo; </p> <p> <a href=\"#footnote-ref-4\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-5\" value=\"14\"> <p class=\"msword-footnote-text\"> We excluded the &ldquo;dummy&rdquo; records from the DE file that represent MSIS IDs present on claims but for which the state submitted no enrollment information. Dummy records can be identified as those with MISG_ELGBLTY_DATA_IND = 1. </p> <p> <a href=\"#footnote-ref-5\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-6\" value=\"15\"> <p class=\"msword-footnote-text\"> If it was available, we used the monthly CHIP code (CHIP_CD) to identify beneficiaries enrolled in Medicaid or CHIP that month (CHIP_CD values of 1&ndash;4). CHIP code 4 (Medicaid and S-CHIP) is a valid value for 2014 through 2017 TAF. If the CHIP code was missing, we considered the beneficiary as enrolled in the month only if the eligibility group variable (ELGBLTY_GRP_CD) was not missing. </p> <p> <a href=\"#footnote-ref-6\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-7\" value=\"16\"> <p class=\"msword-footnote-text\"> TAF claims data are organized by month and year of service. For IP and LT claims, the discharge date (or if that is missing, the service end date) is used to determine the month and year of the service. For OT claims, the service end date is used to determine the month and year of the service. If the service end date is missing, the service start date is used, and if the start date is missing, the most recent service end date from all the claim lines is used. For RX claims, the prescription fill date is used to determine the month and year of the service. </p> <p> <a href=\"#footnote-ref-7\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-8\" value=\"17\"> <p class=\"msword-footnote-text\"> The DSH payment field appears only on IP claims. For LT, OT, and RX claims, we considered only the service tracking payment amount or total Medicaid paid amount. </p> <p> <a href=\"#footnote-ref-8\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-9\" value=\"18\"> <p class=\"msword-footnote-text\"> States sometimes entered the same payment amount in all three payment fields (or two of the three payment fields). To avoid double or triple counting, we used only one payment field per header claim. </p> <p> <a href=\"#footnote-ref-9\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-10\" value=\"19\"> <p class=\"msword-footnote-text\"> If the DSH payment field was zero or missing, we used the service tracking payment amount. If the DSH payment field and service tracking payment amount were both zero or missing, we used the total Medicaid paid amount. </p> <p> <a href=\"#footnote-ref-10\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-11\" value=\"20\"> <p class=\"msword-footnote-text\"> More information about the FASC code can be found in the methodology brief, &ldquo;Assigning TAF Records to a Federally Assigned Service Category,&rdquo; on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources page</a> . </p> <p> <a href=\"#footnote-ref-11\">&uarr;</a> </p> </li></ol>", "footnotes": [{"number": 2, "content": "<li class=\"footnoteBody\" id=\"footnote-2\" value=\"11\"><p class=\"msword-footnote-text\"> Header records summarize the service or the set of linked services provided to a beneficiary. Line records have more detailed information about the services provided. We used the header record for this analysis because most studies in which claims data are used will be based on the summary information in the header record. </p><p><a href=\"#footnote-ref-2\">\u2191</a></p></li>"}, {"number": 3, "content": "<li class=\"footnoteBody\" id=\"footnote-3\" value=\"12\"><p class=\"msword-footnote-text\"> We selected records with claim type code = 1, 2, 4, 5, A, B, D, or E. </p><p><a href=\"#footnote-ref-3\">\u2191</a></p></li>"}, {"number": 4, "content": "<li class=\"footnoteBody\" id=\"footnote-4\" value=\"13\"><p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources page</a> , and a crosswalk of variable names can be found in the guide \u201cProduction of the TAF Research Identifiable Files.\u201d </p><p><a href=\"#footnote-ref-4\">\u2191</a></p></li>"}, {"number": 5, "content": "<li class=\"footnoteBody\" id=\"footnote-5\" value=\"14\"><p class=\"msword-footnote-text\"> We excluded the \u201cdummy\u201d records from the DE file that represent MSIS IDs present on claims but for which the state submitted no enrollment information. Dummy records can be identified as those with MISG_ELGBLTY_DATA_IND = 1. </p><p><a href=\"#footnote-ref-5\">\u2191</a></p></li>"}, {"number": 6, "content": "<li class=\"footnoteBody\" id=\"footnote-6\" value=\"15\"><p class=\"msword-footnote-text\"> If it was available, we used the monthly CHIP code (CHIP_CD) to identify beneficiaries enrolled in Medicaid or CHIP that month (CHIP_CD values of 1\u20134). CHIP code 4 (Medicaid and S-CHIP) is a valid value for 2014 through 2017 TAF. If the CHIP code was missing, we considered the beneficiary as enrolled in the month only if the eligibility group variable (ELGBLTY_GRP_CD) was not missing. </p><p><a href=\"#footnote-ref-6\">\u2191</a></p></li>"}, {"number": 7, "content": "<li class=\"footnoteBody\" id=\"footnote-7\" value=\"16\"><p class=\"msword-footnote-text\"> TAF claims data are organized by month and year of service. For IP and LT claims, the discharge date (or if that is missing, the service end date) is used to determine the month and year of the service. For OT claims, the service end date is used to determine the month and year of the service. If the service end date is missing, the service start date is used, and if the start date is missing, the most recent service end date from all the claim lines is used. For RX claims, the prescription fill date is used to determine the month and year of the service. </p><p><a href=\"#footnote-ref-7\">\u2191</a></p></li>"}, {"number": 8, "content": "<li class=\"footnoteBody\" id=\"footnote-8\" value=\"17\"><p class=\"msword-footnote-text\"> The DSH payment field appears only on IP claims. For LT, OT, and RX claims, we considered only the service tracking payment amount or total Medicaid paid amount. </p><p><a href=\"#footnote-ref-8\">\u2191</a></p></li>"}, {"number": 9, "content": "<li class=\"footnoteBody\" id=\"footnote-9\" value=\"18\"><p class=\"msword-footnote-text\"> States sometimes entered the same payment amount in all three payment fields (or two of the three payment fields). To avoid double or triple counting, we used only one payment field per header claim. </p><p><a href=\"#footnote-ref-9\">\u2191</a></p></li>"}, {"number": 10, "content": "<li class=\"footnoteBody\" id=\"footnote-10\" value=\"19\"><p class=\"msword-footnote-text\"> If the DSH payment field was zero or missing, we used the service tracking payment amount. If the DSH payment field and service tracking payment amount were both zero or missing, we used the total Medicaid paid amount. </p><p><a href=\"#footnote-ref-10\">\u2191</a></p></li>"}, {"number": 11, "content": "<li class=\"footnoteBody\" id=\"footnote-11\" value=\"20\"><p class=\"msword-footnote-text\"> More information about the FASC code can be found in the methodology brief, \u201cAssigning TAF Records to a Federally Assigned Service Category,\u201d on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources page</a> . </p><p><a href=\"#footnote-ref-11\">\u2191</a></p></li>"}]}, "summary": {"content": "<p>Most expenditures in the TAF claims files should link to a beneficiary using the unique identifier that states assign to each beneficiary, the MSIS ID. This analysis examines the proportion of expenditures in the TAF that can be linked to an eligibility record using the MSIS ID.</p>", "footnotes": []}, "originalIssueBriefId": "6071", "relatedTopics": []}
111
{"measureId": 111, "measureName": "Category of Service Code - IP", "groupId": 12, "groupName": "Financial Reporting", "pdfVersionLink": "downloads/background-and-methods/TAF-DQ-Srvc-Cat-Cd-IP.pdf", "background": {"content": "<p class=\"msword-paragraph\"> <a id=\"_Hlk30592933\"></a> <a id=\"_Hlk95402275\"></a> Medicaid and the Children&rsquo;s Health Insurance Program (CHIP) are joint state-federal medical assistance programs in which the state administers the program and pays providers or health plans directly for covered services, and the federal government reimburses a set percentage of the state&rsquo;s expenditures (referred to as the \"federal match\"). Because the federal government applies different federal matching rates to Medicaid and CHIP beneficiaries, states report Medicaid and CHIP expenditure data separately.</p><p class=\"msword-paragraph\"> To claim federal matching funds for their medical assistance programs, states report aggregate expenditure data for Medicaid beneficiaries covered under Title XIX of the Social Security Act to the Centers for Medicare &amp; Medicaid Services (CMS) on Form CMS-64, <em> Quarterly Medicaid Statement of Expenditures. </em> States report aggregate expenditure data for the CHIP beneficiaries covered under Title XXI of the Social Security Act on Form CMS-21, <em> Quarterly CHIP Statement of Expenditures </em> . States may cover children using CHIP funds by expanding their Medicaid programs (called \"Medicaid expansion CHIP,\" or M-CHIP), creating a program separate from their existing Medicaid programs (called \"separate CHIP,\" or S-CHIP), or adopting a combination of both approaches. Expenditures for both M-CHIP and S-CHIP beneficiaries, which qualify for the higher CHIP federal match rate, are reported on Form CMS-21 and not Form CMS-64.</p><p class=\"msword-paragraph\"> There are three data elements in the T-MSIS Analytic Files (TAF) inpatient (IP), long-term care (LT), other services (OT), and pharmacy (RX) files that contain information about how states report Medicaid and CHIP expenditures to claim federal matching funds: the federal reimbursement category code, the CMS-64 category of service code, and the CMS-21 category of service code (Table 1). <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-2\" id=\"footnote-ref-2\">[1]</a> </sup> </sup> The federal reimbursement category code indicates whether the expenditure was reimbursed under Title XIX, Title XXI, the Affordable Care Act (ACA), or other legislation. As noted earlier, if the expenditure was covered by Title XIX of the Social Security Act, it should be reported on Form CMS-64; if the expenditure was covered by Title XXI of the Social Security Act it should be reported on Form CMS-21. The CMS-64 category of service code indicates the specific category of service on Form CMS-64 into which the state will report the Medicaid expenditures associated with a paid claim. The CMS-21 category of service code indicates the specific category of service on Form CMS-21 into which the state will report the CHIP expenditures associated with a paid claim.</p><p class=\"msword-table-title\"> Table 1. TAF variables that classify expenditures into federal reimbursement categories</p><table aria-label=\"Table 1. TAF variables that classify expenditures into federal reimbursement categories\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Variable </p> </th> <th> <p class=\"msword-table-header-center\"> TAF data element name </p> <p class=\"msword-table-header-center\"> (TAF RIF name in parentheses if different) </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> IP, LT, OT, and RX records expected to have non-missing values </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Description </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Federal reimbursement category code </p> </td> <td> <p class=\"msword-table-text-centered\"> CMS_64_FED_REIMBRSMT_CTGRY_CD </p> <p class=\"msword-table-text-centered\"> (CMS_64_FED_CTGRY_CD) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> All records </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> This code indicates whether the claim was matched with federal funding under Title XIX (value of &lsquo;01&rsquo;), Title XXI (&lsquo;02&rsquo;), the Affordable Care Act (&lsquo;03&rsquo;), <sup class=\"msword-superscript\"> a </sup> or federal funding under other legislation (&lsquo;04&rsquo;). </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> CMS-64 category of service code </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> XIX_SRVC_CTGRY_CD </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Only records representing expenditures that the state will report on the CMS-64, which should link to beneficiaries enrolled in non-CHIP Medicaid </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> A four-digit code (from 001A to 0050) indicating the line on the Form CMS-64 on which the state reported the expenditures associated with the claim. The Form CMS-64 is used to report expenditures that qualify for federal matching funds under Title XXI. A full list of the category of service and definition for each line can be found at <a aria-label=\"View Categories of service in the CMS-64 on Medicaid.gov\" href=\"https://www.medicaid.gov/medicaid/downloads/cms-649-base-category-of-services-definition-2-14.pdf\">https://www.medicaid.gov/medicaid/downloads/cms-649-base-category-of-services-definition-2-14.pdf</a> . </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> CMS-21 category of service code </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> XIX_SRVC_CTGRY_CD </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Only records representing expenditures that the state will report on the CMS-21, which should link to beneficiaries enrolled in Medicaid-expansion CHIP or Separate CHIP </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> A three-digit code (from 01A to 35B) indicating the category of service (or line) on the Form CMS-21 on which the state reported the expenditures associated with the claim. The Form CMS-21 is used to report expenditures that qualify for federal matching funds under Title XXI. A full list of the category of service and definition for each line can be found at <a aria-label=\"View MBES Category of Service Definitions for the CMS-21 Base Form\" href=\"https://www.medicaid.gov/medicaid/downloads/cms-21-base-category-of-services-definition-2-14.pdf\">https://www.medicaid.gov/medicaid/downloads/cms-21-base-category-of-services-definition-2-14.pdf</a> . </p> </td> </tr> </tbody></table><p class=\"msword-table-footnote\"> <sup class=\"msword-footnote-reference\"> a </sup> The federal reimbursement category code \"03\" was previously a valid value used by some states on claims for their ACA adult expansion population. However, <a id=\"_Hlk103946431\"></a> CMS retired the \"03\" value in September 2020 and states are expected to use the \"01\" value for this population moving forward since the enhanced match rate for these enrollees is authorized under Title XIX.</p><p class=\"msword-paragraph\"> If states are populating these data elements correctly, claim records that link to beneficiaries enrolled in Title XIX Medicaid will be coded to indicate the expenditure is reportable on Form CMS-64. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-3\" id=\"footnote-ref-3\">[2]</a> </sup> </sup> Similarly, claim records that link to beneficiaries enrolled in Title XXI CHIP&mdash;including both M-CHIP and S-CHIP programs&mdash;will be coded to indicate the expenditure is reportable on Form CMS-21.</p><p class=\"msword-paragraph\"> Other TAF data elements can be used to summarize Medicaid and CHIP spending associated with certain services or benefit categories, including the state-assigned type of service code, the federally-assigned service category code, and the benefit type code. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-4\" id=\"footnote-ref-4\">[3]</a> </sup> </sup> However, those data elements will not necessarily line up with the CMS-64 or CMS-21 categories that states use to report expenditures for the purposes of federal reimbursement.</p><p class=\"msword-paragraph\"> In this data quality assessment, we evaluate the percentage of records in each claims file reported with a federal reimbursement category code that is consistent with the beneficiary&rsquo;s enrollment in the Medicaid or CHIP programs. We also evaluate the percentage of records in each claims file reported with a CMS-64 or CMS-21 category of service code consistent with the beneficiary&rsquo;s enrollment in the Medicaid or CHIP program.</p><ol> <li class=\"footnoteBody\" id=\"footnote-2\" value=\"1\"> <p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page, and a crosswalk of variable names can be found in the guide &ldquo;Production of the TAF Research Identifiable Files.&rdquo; </p> <p> <a href=\"#footnote-ref-2\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-3\" value=\"2\"> <p class=\"msword-footnote-text\"> More information about differences between expenditures in the TAF and the CMS-64 data can be found in the DQ Atlas single topic displays under the Expenditure Benchmarking topic area. </p> <p> <a href=\"#footnote-ref-3\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-4\" value=\"3\"> <p class=\"msword-footnote-text\"> More information on states with missing or invalid type of service code can be found in the DQ Atlas single topic displays for <a aria-label=\"View DQ Atlas single topic display for Type of Service - IP\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m52\">Type of Service - IP</a> , <a aria-label=\"View DQ Atlas single topic display for Type of Service - OT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m53\">Type of Service - OT</a> , <a aria-label=\"View DQ Atlas single topic display for Type of Service - LT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m54\">Type of Service - LT</a> , and <a aria-label=\"View DQ Atlas single topic display for Type of Service - RX\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m55\">Type of Service - RX</a> . For more information about the FASC code, see the methodology brief, &ldquo;Assigning TAF Records to a Federally Assigned Service Category,&rdquo; on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page. </p> <p> <a href=\"#footnote-ref-4\">&uarr;</a> </p> </li></ol>", "footnotes": [{"number": 2, "content": "<li class=\"footnoteBody\" id=\"footnote-2\" value=\"1\"><p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page, and a crosswalk of variable names can be found in the guide \u201cProduction of the TAF Research Identifiable Files.\u201d </p><p><a href=\"#footnote-ref-2\">\u2191</a></p></li>"}, {"number": 3, "content": "<li class=\"footnoteBody\" id=\"footnote-3\" value=\"2\"><p class=\"msword-footnote-text\"> More information about differences between expenditures in the TAF and the CMS-64 data can be found in the DQ Atlas single topic displays under the Expenditure Benchmarking topic area. </p><p><a href=\"#footnote-ref-3\">\u2191</a></p></li>"}, {"number": 4, "content": "<li class=\"footnoteBody\" id=\"footnote-4\" value=\"3\"><p class=\"msword-footnote-text\"> More information on states with missing or invalid type of service code can be found in the DQ Atlas single topic displays for <a aria-label=\"View DQ Atlas single topic display for Type of Service - IP\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m52\">Type of Service - IP</a> , <a aria-label=\"View DQ Atlas single topic display for Type of Service - OT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m53\">Type of Service - OT</a> , <a aria-label=\"View DQ Atlas single topic display for Type of Service - LT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m54\">Type of Service - LT</a> , and <a aria-label=\"View DQ Atlas single topic display for Type of Service - RX\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m55\">Type of Service - RX</a> . For more information about the FASC code, see the methodology brief, \u201cAssigning TAF Records to a Federally Assigned Service Category,\u201d on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page. </p><p><a href=\"#footnote-ref-4\">\u2191</a></p></li>"}]}, "methods": {"content": "<p class=\"msword-paragraph\"> We began by selecting all records from the IP, LT, OT, and RX claims files that represented Medicaid and S-CHIP fee-for-service (FFS), capitation, and supplemental payments based on the claim type code. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-2\" id=\"footnote-ref-2\">[4]</a> </sup> </sup> <sup> , </sup> <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-3\" id=\"footnote-ref-3\">[5]</a> </sup> </sup> We excluded managed care encounter records from the analysis because the payments recorded on those claims do not represent state expenditures and are not recorded on the CMS-64 or CMS-21. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-4\" id=\"footnote-ref-4\">[6]</a> </sup> </sup> We also excluded service tracking claims from the analysis because these records are lump-sum payments that that cannot be linked to an eligibility record. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-5\" id=\"footnote-ref-5\">[7]</a> </sup> </sup></p><p class=\"msword-paragraph\"> To determine whether the beneficiary was enrolled in Medicaid, M-CHIP, or S-CHIP on the date of service, we linked the claims records to the matching eligibility record using the unique beneficiary identifier coded on the claim (MSIS ID). We determined Medicaid, M-CHIP, and S-CHIP enrollment by examining the CHIP code on records in the TAF Demographic and Eligibility (DE) file from the month that corresponded to the date of service on the claim. We excluded from the analysis claims records with a missing or invalid beneficiary identifier. Additionally, we excluded claims that did not link to an eligibility record, as well as those that linked to an eligibility record but did not have a CHIP code populated (indicating the individual was enrolled in Medicaid or CHIP) during the date of service on the claim. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-6\" id=\"footnote-ref-6\">[8]</a> </sup> </sup></p><p class=\"msword-paragraph\"> Finally, we calculated the percentage of records in each file with a federal reimbursement category code consistent with the beneficiary&rsquo;s reported enrollment in Medicaid, M-CHIP, or S-CHIP. The expected coding for federal reimbursement category code based on CHIP code is shown in Table 2. Because Medicaid beneficiaries enrolled in an adult expansion eligibility group may have a different federal reimbursement category code than Medicaid beneficiaries not enrolled in such a group, we examined these two groups of Medicaid beneficiaries separately. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-7\" id=\"footnote-ref-7\">[9]</a> </sup> </sup> We also calculated the percentage of records with a CMS-64 or CMS-21 category of service code consistent with the beneficiary&rsquo;s enrollment in the Medicaid or CHIP program. The expected coding for CMS-64 and CMS-21 category of service code based on CHIP code is shown in Table 3.</p><p class=\"msword-table-title\"> Table 2. Expected coding for federal reimbursement category code</p><table aria-label=\"Table 2. Expected coding for federal reimbursement category code\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Enrollment type </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> CHIP code on eligibility record (CHIP_CD) </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Latest eligibility group on eligibility record (ELGBLTY_GRP_CD_LTST) </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Expected federal reimbursement category code on claim record </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Medicaid &ndash; Adult expansion group </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 1 </strong> (Medicaid) </p> </td> <td> <p class=\"msword-table-text-centered\"> <strong> 72 </strong> (Adult Group - Individuals at or below 133% FPL Age 19 through 64 - newly eligible for all states) </p> <p class=\"msword-table-text-centered\"> <strong> 73 </strong> (Adult Group - Individuals at or below 133% FPL Age 19 through 64- not newly eligible for non 1905z(3) states), </p> <p class=\"msword-table-text-centered\"> <strong> 74 </strong> (Adult Group - Individuals at or below 133% FPL Age 19 through 64 &ndash; not newly eligible parent/ caretaker relative(s) in 1905z(3) states), or </p> <p class=\"msword-table-text-centered\"> <strong> 75 </strong> (Adult Group - Individuals at or below 133% FPL Age 19 through 64- not newly eligible non-parent/ caretaker-relative(s) in 1905z(3) states) </p> </td> <td> <p class=\"msword-table-text-centered\"> <strong> 01 </strong> (Federal funding under Title XIX) or </p> <p class=\"msword-table-text-centered\"> <strong> 03 </strong> (Federal funding under ACA) <sup class=\"msword-superscript\"> a </sup> </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Medicaid &ndash; All other </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 1 </strong> (Medicaid) </p> </td> <td> <p class=\"msword-table-text-centered\"> Any valid code or null/missing, except: </p> <p class=\"msword-table-text-centered\"> <strong> 72, 73, 74, 75, </strong> or </p> <p class=\"msword-table-text-centered\"> <strong> 61-68 </strong> (CHIP eligibility groups) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 01 </strong> (Federal funding under Title XIX) </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> M-CHIP </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 2 </strong> (M-CHIP) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> N/A </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 02 </strong> (Federal funding under Title XXI) </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> S-CHIP </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 3 </strong> (S-CHIP) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> N/A </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 02 </strong> (Federal funding under Title XXI) </p> </td> </tr> </tbody></table><p class=\"msword-table-footnote\"> <sup class=\"msword-footnote-reference\"> a </sup> In this assessment, we consider both \"01\" and \"03\" to be consistent values for Medicaid-enrolled beneficiaries in the adult expansion eligibility groups. The value \"03\" (Federal funding under ACA) was retired as a valid value on September 30, 2020 and while the value is still present in the data before that date, we would expect to see relatively few claims with this value after that date.</p><p class=\"msword-table-footnote\"> ACA = Affordable Care Act; FPL = Federal Poverty Level; N/A = not available.</p><p class=\"msword-table-title\"> Table 3. Expected coding for CMS-64 and CMS-21 category of service codes</p><table aria-label=\"Table 3. Expected coding for CMS-64 and CMS-21 category of service codes\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> CHIP code on eligibility record (CHIP_CD) </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Expected CMS-64 category of service code on claims record </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Expected CMS-21 category of service code on claims record </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> <strong> 1 </strong> (Medicaid) </p> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> Any valid value for CMS-64 category of service </li> </ul> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> Field should be blank </li> </ul> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> <strong> 2 </strong> (M-CHIP) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Field should be blank </p> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> Any valid value for CMS-21 category of service </li> </ul> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> <strong> 3 </strong> (S-CHIP) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Field should be blank </p> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> Any valid value for CMS-21 category of service </li> </ul> </td> </tr> </tbody></table><p class=\"msword-header\"> Data quality assessment criteria</p><p class=\"msword-paragraph\"> We categorized each state as having low, medium, or high data quality concern for the federal reimbursement category code, depending on the percentage of records with a federal reimbursement category code consistent with the beneficiary&rsquo;s enrollment in the Medicaid, M-CHIP, or S-CHIP programs, as shown in Table 4.</p><p class=\"msword-table-title\"> Table 4. Criteria for DQ assessment of federal reimbursement category code</p><table aria-label=\"Table 4. Criteria for DQ assessment of federal reimbursement category code\" class=\"dq-assessment-table\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Percentage of claim lines with a federal reimbursement category code consistent with program enrollment </p> </th> <th class=\"msword-table-header-center dq-assessment-col\"> <p class=\"msword-table-header-center\"> DQ assessment </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &ge; 90 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level low\"> <p class=\"msword-table-text-centered\"> Low concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 80 percent &le; x &lt; 90 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level medium\"> <p class=\"msword-table-text-centered\"> Medium concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 50 percent &le; x &lt; 80 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level high\"> <p class=\"msword-table-text-centered\"> High concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &lt; 50 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level unusable\"> <p class=\"msword-table-text-centered\"> Unusable </p> </td> </tr> </tbody></table><p class=\"msword-paragraph\"> We categorized each state as having low, medium, or high data quality concern for the category of service code, depending on the percentage of records with a CMS-64 or CMS-21 category of service code consistent with the beneficiary&rsquo;s enrollment in the Medicaid, M-CHIP, or S-CHIP programs, as shown in Table 5. As shown in Table 3, only the CMS-64 or CMS-21 category of service code is expected to be populated on a single claim record. When both fields were populated on the same claim (even if one or both values were invalid), that record was inconsistent with enrollment in the Medicaid, M-CHIP, or S-CHIP programs for the purposes of this analysis.</p><p class=\"msword-table-title\"> Table 5. Criteria for DQ assessment of category of service codes</p><table aria-label=\"Table 5. Criteria for DQ assessment of category of service codes\" class=\"dq-assessment-table\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Percentage of claim lines with a CMS-64 category of service code or a CMS-21 category of service code consistent with program enrollment </p> </th> <th class=\"msword-table-header-center dq-assessment-col\"> <p class=\"msword-table-header-center\"> DQ assessment </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &ge; 90 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level low\"> <p class=\"msword-table-text-centered\"> Low concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 80 percent &le; x &lt; 90 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level medium\"> <p class=\"msword-table-text-centered\"> Medium concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 50 percent &le; x &lt; 80 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level high\"> <p class=\"msword-table-text-centered\"> High concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &lt; 50 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level unusable\"> <p class=\"msword-table-text-centered\"> Unusable </p> </td> </tr> </tbody></table><ol> <li class=\"footnoteBody\" id=\"footnote-2\" value=\"4\"> <p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page, and a crosswalk of variable names can be found in the guide &ldquo;Production of the TAF Research Identifiable Files.&rdquo; </p> <p> <a href=\"#footnote-ref-2\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-3\" value=\"5\"> <p class=\"msword-footnote-text\"> FFS claims representing Medicaid or M-CHIP services have a claim type code (CLM_TYPE_CD) value of 1, capitation payments have a claim type code value of 2, and supplemental payments have a claim type code value of 5. FFS claims representing S-CHIP benefits have a claim type code value of A, capitation payments have a claim type code value of B, and supplemental payments have a claim type code value of E. </p> <p> <a href=\"#footnote-ref-3\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-4\" value=\"6\"> <p class=\"msword-footnote-text\"> Payment data on managed care encounter records are redacted from the TAF RIFs. </p> <p> <a href=\"#footnote-ref-4\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-5\" value=\"7\"> <p class=\"msword-footnote-text\"> Managed care encounter records representing Medicaid or M-CHIP services have a claim type code value of 3 and service tracking claims have a claim type code value of 4. Managed care encounter records representing S-CHIP benefits have a claim type code value of C, and service tracking claims have a claim type code value of D. </p> <p> <a href=\"#footnote-ref-5\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-6\" value=\"8\"> <p class=\"msword-footnote-text\"> Once an individual is determined eligible for Medicaid, coverage is effective either on the date of application or the first day of the month of application. Benefits also may be covered retroactively for up to three months prior to the month of application if the individual would have been eligible during that period had he or she applied. States are required to update beneficiaries&rsquo; eligibility records in T-MSIS to reflect the retroactive coverage period. However, if a state did not update the eligibility record of a beneficiary to reflect the retroactive coverage period, enrollment information like CHIP code may be missing during the date of service on a paid claim. </p> <p> <a href=\"#footnote-ref-6\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-7\" value=\"9\"> <p class=\"msword-footnote-text\"> We determined the eligibility group by using ELGBLTY_GRP_CD_LTST, the most recent eligibility group reported for the beneficiary in the calendar year. </p> <p> <a href=\"#footnote-ref-7\">&uarr;</a> </p> </li></ol>", "footnotes": [{"number": 2, "content": "<li class=\"footnoteBody\" id=\"footnote-2\" value=\"4\"><p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page, and a crosswalk of variable names can be found in the guide \u201cProduction of the TAF Research Identifiable Files.\u201d </p><p><a href=\"#footnote-ref-2\">\u2191</a></p></li>"}, {"number": 3, "content": "<li class=\"footnoteBody\" id=\"footnote-3\" value=\"5\"><p class=\"msword-footnote-text\"> FFS claims representing Medicaid or M-CHIP services have a claim type code (CLM_TYPE_CD) value of 1, capitation payments have a claim type code value of 2, and supplemental payments have a claim type code value of 5. FFS claims representing S-CHIP benefits have a claim type code value of A, capitation payments have a claim type code value of B, and supplemental payments have a claim type code value of E. </p><p><a href=\"#footnote-ref-3\">\u2191</a></p></li>"}, {"number": 4, "content": "<li class=\"footnoteBody\" id=\"footnote-4\" value=\"6\"><p class=\"msword-footnote-text\"> Payment data on managed care encounter records are redacted from the TAF RIFs. </p><p><a href=\"#footnote-ref-4\">\u2191</a></p></li>"}, {"number": 5, "content": "<li class=\"footnoteBody\" id=\"footnote-5\" value=\"7\"><p class=\"msword-footnote-text\"> Managed care encounter records representing Medicaid or M-CHIP services have a claim type code value of 3 and service tracking claims have a claim type code value of 4. Managed care encounter records representing S-CHIP benefits have a claim type code value of C, and service tracking claims have a claim type code value of D. </p><p><a href=\"#footnote-ref-5\">\u2191</a></p></li>"}, {"number": 6, "content": "<li class=\"footnoteBody\" id=\"footnote-6\" value=\"8\"><p class=\"msword-footnote-text\"> Once an individual is determined eligible for Medicaid, coverage is effective either on the date of application or the first day of the month of application. Benefits also may be covered retroactively for up to three months prior to the month of application if the individual would have been eligible during that period had he or she applied. States are required to update beneficiaries\u2019 eligibility records in T-MSIS to reflect the retroactive coverage period. However, if a state did not update the eligibility record of a beneficiary to reflect the retroactive coverage period, enrollment information like CHIP code may be missing during the date of service on a paid claim. </p><p><a href=\"#footnote-ref-6\">\u2191</a></p></li>"}, {"number": 7, "content": "<li class=\"footnoteBody\" id=\"footnote-7\" value=\"9\"><p class=\"msword-footnote-text\"> We determined the eligibility group by using ELGBLTY_GRP_CD_LTST, the most recent eligibility group reported for the beneficiary in the calendar year. </p><p><a href=\"#footnote-ref-7\">\u2191</a></p></li>"}]}, "summary": {"content": "<p>States report quarterly Medicaid expenditures on Form CMS-64 and quarterly Children's Health Insurance Program (CHIP) expenditures on Form CMS-21 to claim federal matching funds. In the T-MSIS Analytic Files (TAF), the CMS-64 category of service code data element on paid claim records should reflect the category where expenditures for the service are reported on Form CMS-64. Similarly, the CMS-21 category of service code on a paid claim record should reflect the category where expenditures for the service are reported on Form CMS-21. This analysis examines the extent to which records in the IP file are reported with a CMS-64 or CMS-21 category of service code value consistent with the beneficiary's enrollment in the Medicaid or CHIP program.</p>", "footnotes": []}, "originalIssueBriefId": "5221", "relatedTopics": [{"measureId": 112, "measureName": "Category of Service Code - LT", "groupId": 12, "groupName": "Financial Reporting", "order": 1}, {"measureId": 113, "measureName": "Category of Service Code - OT", "groupId": 12, "groupName": "Financial Reporting", "order": 2}, {"measureId": 114, "measureName": "Category of Service Code - RX", "groupId": 12, "groupName": "Financial Reporting", "order": 3}, {"measureId": 115, "measureName": "Federal Reimbursement Category Code - IP", "groupId": 12, "groupName": "Financial Reporting", "order": 4}, {"measureId": 116, "measureName": "Federal Reimbursement Category Code - LT", "groupId": 12, "groupName": "Financial Reporting", "order": 5}, {"measureId": 117, "measureName": "Federal Reimbursement Category Code - OT", "groupId": 12, "groupName": "Financial Reporting", "order": 6}, {"measureId": 118, "measureName": "Federal Reimbursement Category Code - RX", "groupId": 12, "groupName": "Financial Reporting", "order": 7}]}
112
{"measureId": 112, "measureName": "Category of Service Code - LT", "groupId": 12, "groupName": "Financial Reporting", "pdfVersionLink": "downloads/background-and-methods/TAF-DQ-Srvc-Cat-Cd-LT.pdf", "background": {"content": "<p class=\"msword-paragraph\"> <a id=\"_Hlk30592933\"></a> <a id=\"_Hlk95402275\"></a> Medicaid and the Children&rsquo;s Health Insurance Program (CHIP) are joint state-federal medical assistance programs in which the state administers the program and pays providers or health plans directly for covered services, and the federal government reimburses a set percentage of the state&rsquo;s expenditures (referred to as the \"federal match\"). Because the federal government applies different federal matching rates to Medicaid and CHIP beneficiaries, states report Medicaid and CHIP expenditure data separately.</p><p class=\"msword-paragraph\"> To claim federal matching funds for their medical assistance programs, states report aggregate expenditure data for Medicaid beneficiaries covered under Title XIX of the Social Security Act to the Centers for Medicare &amp; Medicaid Services (CMS) on Form CMS-64, <em> Quarterly Medicaid Statement of Expenditures. </em> States report aggregate expenditure data for the CHIP beneficiaries covered under Title XXI of the Social Security Act on Form CMS-21, <em> Quarterly CHIP Statement of Expenditures </em> . States may cover children using CHIP funds by expanding their Medicaid programs (called \"Medicaid expansion CHIP,\" or M-CHIP), creating a program separate from their existing Medicaid programs (called \"separate CHIP,\" or S-CHIP), or adopting a combination of both approaches. Expenditures for both M-CHIP and S-CHIP beneficiaries, which qualify for the higher CHIP federal match rate, are reported on Form CMS-21 and not Form CMS-64.</p><p class=\"msword-paragraph\"> There are three data elements in the T-MSIS Analytic Files (TAF) inpatient (IP), long-term care (LT), other services (OT), and pharmacy (RX) files that contain information about how states report Medicaid and CHIP expenditures to claim federal matching funds: the federal reimbursement category code, the CMS-64 category of service code, and the CMS-21 category of service code (Table 1). <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-2\" id=\"footnote-ref-2\">[1]</a> </sup> </sup> The federal reimbursement category code indicates whether the expenditure was reimbursed under Title XIX, Title XXI, the Affordable Care Act (ACA), or other legislation. As noted earlier, if the expenditure was covered by Title XIX of the Social Security Act, it should be reported on Form CMS-64; if the expenditure was covered by Title XXI of the Social Security Act it should be reported on Form CMS-21. The CMS-64 category of service code indicates the specific category of service on Form CMS-64 into which the state will report the Medicaid expenditures associated with a paid claim. The CMS-21 category of service code indicates the specific category of service on Form CMS-21 into which the state will report the CHIP expenditures associated with a paid claim.</p><p class=\"msword-table-title\"> Table 1. TAF variables that classify expenditures into federal reimbursement categories</p><table aria-label=\"Table 1. TAF variables that classify expenditures into federal reimbursement categories\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Variable </p> </th> <th> <p class=\"msword-table-header-center\"> TAF data element name </p> <p class=\"msword-table-header-center\"> (TAF RIF name in parentheses if different) </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> IP, LT, OT, and RX records expected to have non-missing values </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Description </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Federal reimbursement category code </p> </td> <td> <p class=\"msword-table-text-centered\"> CMS_64_FED_REIMBRSMT_CTGRY_CD </p> <p class=\"msword-table-text-centered\"> (CMS_64_FED_CTGRY_CD) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> All records </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> This code indicates whether the claim was matched with federal funding under Title XIX (value of &lsquo;01&rsquo;), Title XXI (&lsquo;02&rsquo;), the Affordable Care Act (&lsquo;03&rsquo;), <sup class=\"msword-superscript\"> a </sup> or federal funding under other legislation (&lsquo;04&rsquo;). </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> CMS-64 category of service code </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> XIX_SRVC_CTGRY_CD </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Only records representing expenditures that the state will report on the CMS-64, which should link to beneficiaries enrolled in non-CHIP Medicaid </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> A four-digit code (from 001A to 0050) indicating the line on the Form CMS-64 on which the state reported the expenditures associated with the claim. The Form CMS-64 is used to report expenditures that qualify for federal matching funds under Title XXI. A full list of the category of service and definition for each line can be found at <a aria-label=\"View Categories of service in the CMS-64 on Medicaid.gov\" href=\"https://www.medicaid.gov/medicaid/downloads/cms-649-base-category-of-services-definition-2-14.pdf\">https://www.medicaid.gov/medicaid/downloads/cms-649-base-category-of-services-definition-2-14.pdf</a> . </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> CMS-21 category of service code </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> XIX_SRVC_CTGRY_CD </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Only records representing expenditures that the state will report on the CMS-21, which should link to beneficiaries enrolled in Medicaid-expansion CHIP or Separate CHIP </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> A three-digit code (from 01A to 35B) indicating the category of service (or line) on the Form CMS-21 on which the state reported the expenditures associated with the claim. The Form CMS-21 is used to report expenditures that qualify for federal matching funds under Title XXI. A full list of the category of service and definition for each line can be found at <a aria-label=\"View MBES Category of Service Definitions for the CMS-21 Base Form\" href=\"https://www.medicaid.gov/medicaid/downloads/cms-21-base-category-of-services-definition-2-14.pdf\">https://www.medicaid.gov/medicaid/downloads/cms-21-base-category-of-services-definition-2-14.pdf</a> . </p> </td> </tr> </tbody></table><p class=\"msword-table-footnote\"> <sup class=\"msword-footnote-reference\"> a </sup> The federal reimbursement category code \"03\" was previously a valid value used by some states on claims for their ACA adult expansion population. However, <a id=\"_Hlk103946431\"></a> CMS retired the \"03\" value in September 2020 and states are expected to use the \"01\" value for this population moving forward since the enhanced match rate for these enrollees is authorized under Title XIX.</p><p class=\"msword-paragraph\"> If states are populating these data elements correctly, claim records that link to beneficiaries enrolled in Title XIX Medicaid will be coded to indicate the expenditure is reportable on Form CMS-64. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-3\" id=\"footnote-ref-3\">[2]</a> </sup> </sup> Similarly, claim records that link to beneficiaries enrolled in Title XXI CHIP&mdash;including both M-CHIP and S-CHIP programs&mdash;will be coded to indicate the expenditure is reportable on Form CMS-21.</p><p class=\"msword-paragraph\"> Other TAF data elements can be used to summarize Medicaid and CHIP spending associated with certain services or benefit categories, including the state-assigned type of service code, the federally-assigned service category code, and the benefit type code. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-4\" id=\"footnote-ref-4\">[3]</a> </sup> </sup> However, those data elements will not necessarily line up with the CMS-64 or CMS-21 categories that states use to report expenditures for the purposes of federal reimbursement.</p><p class=\"msword-paragraph\"> In this data quality assessment, we evaluate the percentage of records in each claims file reported with a federal reimbursement category code that is consistent with the beneficiary&rsquo;s enrollment in the Medicaid or CHIP programs. We also evaluate the percentage of records in each claims file reported with a CMS-64 or CMS-21 category of service code consistent with the beneficiary&rsquo;s enrollment in the Medicaid or CHIP program.</p><ol> <li class=\"footnoteBody\" id=\"footnote-2\" value=\"1\"> <p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page, and a crosswalk of variable names can be found in the guide &ldquo;Production of the TAF Research Identifiable Files.&rdquo; </p> <p> <a href=\"#footnote-ref-2\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-3\" value=\"2\"> <p class=\"msword-footnote-text\"> More information about differences between expenditures in the TAF and the CMS-64 data can be found in the DQ Atlas single topic displays under the Expenditure Benchmarking topic area. </p> <p> <a href=\"#footnote-ref-3\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-4\" value=\"3\"> <p class=\"msword-footnote-text\"> More information on states with missing or invalid type of service code can be found in the DQ Atlas single topic displays for <a aria-label=\"View DQ Atlas single topic display for Type of Service - IP\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m52\">Type of Service - IP</a> , <a aria-label=\"View DQ Atlas single topic display for Type of Service - OT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m53\">Type of Service - OT</a> , <a aria-label=\"View DQ Atlas single topic display for Type of Service - LT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m54\">Type of Service - LT</a> , and <a aria-label=\"View DQ Atlas single topic display for Type of Service - RX\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m55\">Type of Service - RX</a> . For more information about the FASC code, see the methodology brief, &ldquo;Assigning TAF Records to a Federally Assigned Service Category,&rdquo; on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page. </p> <p> <a href=\"#footnote-ref-4\">&uarr;</a> </p> </li></ol>", "footnotes": [{"number": 2, "content": "<li class=\"footnoteBody\" id=\"footnote-2\" value=\"1\"><p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page, and a crosswalk of variable names can be found in the guide \u201cProduction of the TAF Research Identifiable Files.\u201d </p><p><a href=\"#footnote-ref-2\">\u2191</a></p></li>"}, {"number": 3, "content": "<li class=\"footnoteBody\" id=\"footnote-3\" value=\"2\"><p class=\"msword-footnote-text\"> More information about differences between expenditures in the TAF and the CMS-64 data can be found in the DQ Atlas single topic displays under the Expenditure Benchmarking topic area. </p><p><a href=\"#footnote-ref-3\">\u2191</a></p></li>"}, {"number": 4, "content": "<li class=\"footnoteBody\" id=\"footnote-4\" value=\"3\"><p class=\"msword-footnote-text\"> More information on states with missing or invalid type of service code can be found in the DQ Atlas single topic displays for <a aria-label=\"View DQ Atlas single topic display for Type of Service - IP\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m52\">Type of Service - IP</a> , <a aria-label=\"View DQ Atlas single topic display for Type of Service - OT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m53\">Type of Service - OT</a> , <a aria-label=\"View DQ Atlas single topic display for Type of Service - LT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m54\">Type of Service - LT</a> , and <a aria-label=\"View DQ Atlas single topic display for Type of Service - RX\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m55\">Type of Service - RX</a> . For more information about the FASC code, see the methodology brief, \u201cAssigning TAF Records to a Federally Assigned Service Category,\u201d on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page. </p><p><a href=\"#footnote-ref-4\">\u2191</a></p></li>"}]}, "methods": {"content": "<p class=\"msword-paragraph\"> We began by selecting all records from the IP, LT, OT, and RX claims files that represented Medicaid and S-CHIP fee-for-service (FFS), capitation, and supplemental payments based on the claim type code. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-2\" id=\"footnote-ref-2\">[4]</a> </sup> </sup> <sup> , </sup> <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-3\" id=\"footnote-ref-3\">[5]</a> </sup> </sup> We excluded managed care encounter records from the analysis because the payments recorded on those claims do not represent state expenditures and are not recorded on the CMS-64 or CMS-21. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-4\" id=\"footnote-ref-4\">[6]</a> </sup> </sup> We also excluded service tracking claims from the analysis because these records are lump-sum payments that that cannot be linked to an eligibility record. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-5\" id=\"footnote-ref-5\">[7]</a> </sup> </sup></p><p class=\"msword-paragraph\"> To determine whether the beneficiary was enrolled in Medicaid, M-CHIP, or S-CHIP on the date of service, we linked the claims records to the matching eligibility record using the unique beneficiary identifier coded on the claim (MSIS ID). We determined Medicaid, M-CHIP, and S-CHIP enrollment by examining the CHIP code on records in the TAF Demographic and Eligibility (DE) file from the month that corresponded to the date of service on the claim. We excluded from the analysis claims records with a missing or invalid beneficiary identifier. Additionally, we excluded claims that did not link to an eligibility record, as well as those that linked to an eligibility record but did not have a CHIP code populated (indicating the individual was enrolled in Medicaid or CHIP) during the date of service on the claim. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-6\" id=\"footnote-ref-6\">[8]</a> </sup> </sup></p><p class=\"msword-paragraph\"> Finally, we calculated the percentage of records in each file with a federal reimbursement category code consistent with the beneficiary&rsquo;s reported enrollment in Medicaid, M-CHIP, or S-CHIP. The expected coding for federal reimbursement category code based on CHIP code is shown in Table 2. Because Medicaid beneficiaries enrolled in an adult expansion eligibility group may have a different federal reimbursement category code than Medicaid beneficiaries not enrolled in such a group, we examined these two groups of Medicaid beneficiaries separately. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-7\" id=\"footnote-ref-7\">[9]</a> </sup> </sup> We also calculated the percentage of records with a CMS-64 or CMS-21 category of service code consistent with the beneficiary&rsquo;s enrollment in the Medicaid or CHIP program. The expected coding for CMS-64 and CMS-21 category of service code based on CHIP code is shown in Table 3.</p><p class=\"msword-table-title\"> Table 2. Expected coding for federal reimbursement category code</p><table aria-label=\"Table 2. Expected coding for federal reimbursement category code\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Enrollment type </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> CHIP code on eligibility record (CHIP_CD) </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Latest eligibility group on eligibility record (ELGBLTY_GRP_CD_LTST) </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Expected federal reimbursement category code on claim record </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Medicaid &ndash; Adult expansion group </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 1 </strong> (Medicaid) </p> </td> <td> <p class=\"msword-table-text-centered\"> <strong> 72 </strong> (Adult Group - Individuals at or below 133% FPL Age 19 through 64 - newly eligible for all states) </p> <p class=\"msword-table-text-centered\"> <strong> 73 </strong> (Adult Group - Individuals at or below 133% FPL Age 19 through 64- not newly eligible for non 1905z(3) states), </p> <p class=\"msword-table-text-centered\"> <strong> 74 </strong> (Adult Group - Individuals at or below 133% FPL Age 19 through 64 &ndash; not newly eligible parent/ caretaker relative(s) in 1905z(3) states), or </p> <p class=\"msword-table-text-centered\"> <strong> 75 </strong> (Adult Group - Individuals at or below 133% FPL Age 19 through 64- not newly eligible non-parent/ caretaker-relative(s) in 1905z(3) states) </p> </td> <td> <p class=\"msword-table-text-centered\"> <strong> 01 </strong> (Federal funding under Title XIX) or </p> <p class=\"msword-table-text-centered\"> <strong> 03 </strong> (Federal funding under ACA) <sup class=\"msword-superscript\"> a </sup> </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Medicaid &ndash; All other </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 1 </strong> (Medicaid) </p> </td> <td> <p class=\"msword-table-text-centered\"> Any valid code or null/missing, except: </p> <p class=\"msword-table-text-centered\"> <strong> 72, 73, 74, 75, </strong> or </p> <p class=\"msword-table-text-centered\"> <strong> 61-68 </strong> (CHIP eligibility groups) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 01 </strong> (Federal funding under Title XIX) </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> M-CHIP </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 2 </strong> (M-CHIP) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> N/A </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 02 </strong> (Federal funding under Title XXI) </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> S-CHIP </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 3 </strong> (S-CHIP) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> N/A </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 02 </strong> (Federal funding under Title XXI) </p> </td> </tr> </tbody></table><p class=\"msword-table-footnote\"> <sup class=\"msword-footnote-reference\"> a </sup> In this assessment, we consider both \"01\" and \"03\" to be consistent values for Medicaid-enrolled beneficiaries in the adult expansion eligibility groups. The value \"03\" (Federal funding under ACA) was retired as a valid value on September 30, 2020 and while the value is still present in the data before that date, we would expect to see relatively few claims with this value after that date.</p><p class=\"msword-table-footnote\"> ACA = Affordable Care Act; FPL = Federal Poverty Level; N/A = not available.</p><p class=\"msword-table-title\"> Table 3. Expected coding for CMS-64 and CMS-21 category of service codes</p><table aria-label=\"Table 3. Expected coding for CMS-64 and CMS-21 category of service codes\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> CHIP code on eligibility record (CHIP_CD) </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Expected CMS-64 category of service code on claims record </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Expected CMS-21 category of service code on claims record </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> <strong> 1 </strong> (Medicaid) </p> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> Any valid value for CMS-64 category of service </li> </ul> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> Field should be blank </li> </ul> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> <strong> 2 </strong> (M-CHIP) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Field should be blank </p> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> Any valid value for CMS-21 category of service </li> </ul> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> <strong> 3 </strong> (S-CHIP) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Field should be blank </p> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> Any valid value for CMS-21 category of service </li> </ul> </td> </tr> </tbody></table><p class=\"msword-header\"> Data quality assessment criteria</p><p class=\"msword-paragraph\"> We categorized each state as having low, medium, or high data quality concern for the federal reimbursement category code, depending on the percentage of records with a federal reimbursement category code consistent with the beneficiary&rsquo;s enrollment in the Medicaid, M-CHIP, or S-CHIP programs, as shown in Table 4.</p><p class=\"msword-table-title\"> Table 4. Criteria for DQ assessment of federal reimbursement category code</p><table aria-label=\"Table 4. Criteria for DQ assessment of federal reimbursement category code\" class=\"dq-assessment-table\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Percentage of claim lines with a federal reimbursement category code consistent with program enrollment </p> </th> <th class=\"msword-table-header-center dq-assessment-col\"> <p class=\"msword-table-header-center\"> DQ assessment </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &ge; 90 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level low\"> <p class=\"msword-table-text-centered\"> Low concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 80 percent &le; x &lt; 90 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level medium\"> <p class=\"msword-table-text-centered\"> Medium concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 50 percent &le; x &lt; 80 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level high\"> <p class=\"msword-table-text-centered\"> High concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &lt; 50 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level unusable\"> <p class=\"msword-table-text-centered\"> Unusable </p> </td> </tr> </tbody></table><p class=\"msword-paragraph\"> We categorized each state as having low, medium, or high data quality concern for the category of service code, depending on the percentage of records with a CMS-64 or CMS-21 category of service code consistent with the beneficiary&rsquo;s enrollment in the Medicaid, M-CHIP, or S-CHIP programs, as shown in Table 5. As shown in Table 3, only the CMS-64 or CMS-21 category of service code is expected to be populated on a single claim record. When both fields were populated on the same claim (even if one or both values were invalid), that record was inconsistent with enrollment in the Medicaid, M-CHIP, or S-CHIP programs for the purposes of this analysis.</p><p class=\"msword-table-title\"> Table 5. Criteria for DQ assessment of category of service codes</p><table aria-label=\"Table 5. Criteria for DQ assessment of category of service codes\" class=\"dq-assessment-table\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Percentage of claim lines with a CMS-64 category of service code or a CMS-21 category of service code consistent with program enrollment </p> </th> <th class=\"msword-table-header-center dq-assessment-col\"> <p class=\"msword-table-header-center\"> DQ assessment </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &ge; 90 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level low\"> <p class=\"msword-table-text-centered\"> Low concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 80 percent &le; x &lt; 90 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level medium\"> <p class=\"msword-table-text-centered\"> Medium concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 50 percent &le; x &lt; 80 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level high\"> <p class=\"msword-table-text-centered\"> High concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &lt; 50 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level unusable\"> <p class=\"msword-table-text-centered\"> Unusable </p> </td> </tr> </tbody></table><ol> <li class=\"footnoteBody\" id=\"footnote-2\" value=\"4\"> <p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page, and a crosswalk of variable names can be found in the guide &ldquo;Production of the TAF Research Identifiable Files.&rdquo; </p> <p> <a href=\"#footnote-ref-2\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-3\" value=\"5\"> <p class=\"msword-footnote-text\"> FFS claims representing Medicaid or M-CHIP services have a claim type code (CLM_TYPE_CD) value of 1, capitation payments have a claim type code value of 2, and supplemental payments have a claim type code value of 5. FFS claims representing S-CHIP benefits have a claim type code value of A, capitation payments have a claim type code value of B, and supplemental payments have a claim type code value of E. </p> <p> <a href=\"#footnote-ref-3\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-4\" value=\"6\"> <p class=\"msword-footnote-text\"> Payment data on managed care encounter records are redacted from the TAF RIFs. </p> <p> <a href=\"#footnote-ref-4\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-5\" value=\"7\"> <p class=\"msword-footnote-text\"> Managed care encounter records representing Medicaid or M-CHIP services have a claim type code value of 3 and service tracking claims have a claim type code value of 4. Managed care encounter records representing S-CHIP benefits have a claim type code value of C, and service tracking claims have a claim type code value of D. </p> <p> <a href=\"#footnote-ref-5\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-6\" value=\"8\"> <p class=\"msword-footnote-text\"> Once an individual is determined eligible for Medicaid, coverage is effective either on the date of application or the first day of the month of application. Benefits also may be covered retroactively for up to three months prior to the month of application if the individual would have been eligible during that period had he or she applied. States are required to update beneficiaries&rsquo; eligibility records in T-MSIS to reflect the retroactive coverage period. However, if a state did not update the eligibility record of a beneficiary to reflect the retroactive coverage period, enrollment information like CHIP code may be missing during the date of service on a paid claim. </p> <p> <a href=\"#footnote-ref-6\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-7\" value=\"9\"> <p class=\"msword-footnote-text\"> We determined the eligibility group by using ELGBLTY_GRP_CD_LTST, the most recent eligibility group reported for the beneficiary in the calendar year. </p> <p> <a href=\"#footnote-ref-7\">&uarr;</a> </p> </li></ol>", "footnotes": [{"number": 2, "content": "<li class=\"footnoteBody\" id=\"footnote-2\" value=\"4\"><p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page, and a crosswalk of variable names can be found in the guide \u201cProduction of the TAF Research Identifiable Files.\u201d </p><p><a href=\"#footnote-ref-2\">\u2191</a></p></li>"}, {"number": 3, "content": "<li class=\"footnoteBody\" id=\"footnote-3\" value=\"5\"><p class=\"msword-footnote-text\"> FFS claims representing Medicaid or M-CHIP services have a claim type code (CLM_TYPE_CD) value of 1, capitation payments have a claim type code value of 2, and supplemental payments have a claim type code value of 5. FFS claims representing S-CHIP benefits have a claim type code value of A, capitation payments have a claim type code value of B, and supplemental payments have a claim type code value of E. </p><p><a href=\"#footnote-ref-3\">\u2191</a></p></li>"}, {"number": 4, "content": "<li class=\"footnoteBody\" id=\"footnote-4\" value=\"6\"><p class=\"msword-footnote-text\"> Payment data on managed care encounter records are redacted from the TAF RIFs. </p><p><a href=\"#footnote-ref-4\">\u2191</a></p></li>"}, {"number": 5, "content": "<li class=\"footnoteBody\" id=\"footnote-5\" value=\"7\"><p class=\"msword-footnote-text\"> Managed care encounter records representing Medicaid or M-CHIP services have a claim type code value of 3 and service tracking claims have a claim type code value of 4. Managed care encounter records representing S-CHIP benefits have a claim type code value of C, and service tracking claims have a claim type code value of D. </p><p><a href=\"#footnote-ref-5\">\u2191</a></p></li>"}, {"number": 6, "content": "<li class=\"footnoteBody\" id=\"footnote-6\" value=\"8\"><p class=\"msword-footnote-text\"> Once an individual is determined eligible for Medicaid, coverage is effective either on the date of application or the first day of the month of application. Benefits also may be covered retroactively for up to three months prior to the month of application if the individual would have been eligible during that period had he or she applied. States are required to update beneficiaries\u2019 eligibility records in T-MSIS to reflect the retroactive coverage period. However, if a state did not update the eligibility record of a beneficiary to reflect the retroactive coverage period, enrollment information like CHIP code may be missing during the date of service on a paid claim. </p><p><a href=\"#footnote-ref-6\">\u2191</a></p></li>"}, {"number": 7, "content": "<li class=\"footnoteBody\" id=\"footnote-7\" value=\"9\"><p class=\"msword-footnote-text\"> We determined the eligibility group by using ELGBLTY_GRP_CD_LTST, the most recent eligibility group reported for the beneficiary in the calendar year. </p><p><a href=\"#footnote-ref-7\">\u2191</a></p></li>"}]}, "summary": {"content": "<p>States report quarterly Medicaid expenditures on Form CMS-64 and quarterly Children's Health Insurance Program (CHIP) expenditures on Form CMS-21 to claim federal matching funds. In the T-MSIS Analytic Files (TAF), the CMS-64 category of service code data element on paid claim records should reflect the category where expenditures for the service are reported on Form CMS-64. Similarly, the CMS-21 category of service code on a paid claim record should reflect the category where expenditures for the service are reported on Form CMS-21. This analysis examines the extent to which records in the LT file are reported with a CMS-64 or CMS-21 category of service code value consistent with the beneficiary's enrollment in the Medicaid or CHIP program.</p>", "footnotes": []}, "originalIssueBriefId": "5221", "relatedTopics": [{"measureId": 111, "measureName": "Category of Service Code - IP", "groupId": 12, "groupName": "Financial Reporting", "order": 0}, {"measureId": 113, "measureName": "Category of Service Code - OT", "groupId": 12, "groupName": "Financial Reporting", "order": 2}, {"measureId": 114, "measureName": "Category of Service Code - RX", "groupId": 12, "groupName": "Financial Reporting", "order": 3}, {"measureId": 115, "measureName": "Federal Reimbursement Category Code - IP", "groupId": 12, "groupName": "Financial Reporting", "order": 4}, {"measureId": 116, "measureName": "Federal Reimbursement Category Code - LT", "groupId": 12, "groupName": "Financial Reporting", "order": 5}, {"measureId": 117, "measureName": "Federal Reimbursement Category Code - OT", "groupId": 12, "groupName": "Financial Reporting", "order": 6}, {"measureId": 118, "measureName": "Federal Reimbursement Category Code - RX", "groupId": 12, "groupName": "Financial Reporting", "order": 7}]}
113
{"measureId": 113, "measureName": "Category of Service Code - OT", "groupId": 12, "groupName": "Financial Reporting", "pdfVersionLink": "downloads/background-and-methods/TAF-DQ-Srvc-Cat-Cd-OT.pdf", "background": {"content": "<p class=\"msword-paragraph\"> <a id=\"_Hlk30592933\"></a> <a id=\"_Hlk95402275\"></a> Medicaid and the Children&rsquo;s Health Insurance Program (CHIP) are joint state-federal medical assistance programs in which the state administers the program and pays providers or health plans directly for covered services, and the federal government reimburses a set percentage of the state&rsquo;s expenditures (referred to as the \"federal match\"). Because the federal government applies different federal matching rates to Medicaid and CHIP beneficiaries, states report Medicaid and CHIP expenditure data separately.</p><p class=\"msword-paragraph\"> To claim federal matching funds for their medical assistance programs, states report aggregate expenditure data for Medicaid beneficiaries covered under Title XIX of the Social Security Act to the Centers for Medicare &amp; Medicaid Services (CMS) on Form CMS-64, <em> Quarterly Medicaid Statement of Expenditures. </em> States report aggregate expenditure data for the CHIP beneficiaries covered under Title XXI of the Social Security Act on Form CMS-21, <em> Quarterly CHIP Statement of Expenditures </em> . States may cover children using CHIP funds by expanding their Medicaid programs (called \"Medicaid expansion CHIP,\" or M-CHIP), creating a program separate from their existing Medicaid programs (called \"separate CHIP,\" or S-CHIP), or adopting a combination of both approaches. Expenditures for both M-CHIP and S-CHIP beneficiaries, which qualify for the higher CHIP federal match rate, are reported on Form CMS-21 and not Form CMS-64.</p><p class=\"msword-paragraph\"> There are three data elements in the T-MSIS Analytic Files (TAF) inpatient (IP), long-term care (LT), other services (OT), and pharmacy (RX) files that contain information about how states report Medicaid and CHIP expenditures to claim federal matching funds: the federal reimbursement category code, the CMS-64 category of service code, and the CMS-21 category of service code (Table 1). <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-2\" id=\"footnote-ref-2\">[1]</a> </sup> </sup> The federal reimbursement category code indicates whether the expenditure was reimbursed under Title XIX, Title XXI, the Affordable Care Act (ACA), or other legislation. As noted earlier, if the expenditure was covered by Title XIX of the Social Security Act, it should be reported on Form CMS-64; if the expenditure was covered by Title XXI of the Social Security Act it should be reported on Form CMS-21. The CMS-64 category of service code indicates the specific category of service on Form CMS-64 into which the state will report the Medicaid expenditures associated with a paid claim. The CMS-21 category of service code indicates the specific category of service on Form CMS-21 into which the state will report the CHIP expenditures associated with a paid claim.</p><p class=\"msword-table-title\"> Table 1. TAF variables that classify expenditures into federal reimbursement categories</p><table aria-label=\"Table 1. TAF variables that classify expenditures into federal reimbursement categories\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Variable </p> </th> <th> <p class=\"msword-table-header-center\"> TAF data element name </p> <p class=\"msword-table-header-center\"> (TAF RIF name in parentheses if different) </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> IP, LT, OT, and RX records expected to have non-missing values </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Description </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Federal reimbursement category code </p> </td> <td> <p class=\"msword-table-text-centered\"> CMS_64_FED_REIMBRSMT_CTGRY_CD </p> <p class=\"msword-table-text-centered\"> (CMS_64_FED_CTGRY_CD) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> All records </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> This code indicates whether the claim was matched with federal funding under Title XIX (value of &lsquo;01&rsquo;), Title XXI (&lsquo;02&rsquo;), the Affordable Care Act (&lsquo;03&rsquo;), <sup class=\"msword-superscript\"> a </sup> or federal funding under other legislation (&lsquo;04&rsquo;). </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> CMS-64 category of service code </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> XIX_SRVC_CTGRY_CD </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Only records representing expenditures that the state will report on the CMS-64, which should link to beneficiaries enrolled in non-CHIP Medicaid </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> A four-digit code (from 001A to 0050) indicating the line on the Form CMS-64 on which the state reported the expenditures associated with the claim. The Form CMS-64 is used to report expenditures that qualify for federal matching funds under Title XXI. A full list of the category of service and definition for each line can be found at <a aria-label=\"View Categories of service in the CMS-64 on Medicaid.gov\" href=\"https://www.medicaid.gov/medicaid/downloads/cms-649-base-category-of-services-definition-2-14.pdf\">https://www.medicaid.gov/medicaid/downloads/cms-649-base-category-of-services-definition-2-14.pdf</a> . </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> CMS-21 category of service code </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> XIX_SRVC_CTGRY_CD </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Only records representing expenditures that the state will report on the CMS-21, which should link to beneficiaries enrolled in Medicaid-expansion CHIP or Separate CHIP </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> A three-digit code (from 01A to 35B) indicating the category of service (or line) on the Form CMS-21 on which the state reported the expenditures associated with the claim. The Form CMS-21 is used to report expenditures that qualify for federal matching funds under Title XXI. A full list of the category of service and definition for each line can be found at <a aria-label=\"View MBES Category of Service Definitions for the CMS-21 Base Form\" href=\"https://www.medicaid.gov/medicaid/downloads/cms-21-base-category-of-services-definition-2-14.pdf\">https://www.medicaid.gov/medicaid/downloads/cms-21-base-category-of-services-definition-2-14.pdf</a> . </p> </td> </tr> </tbody></table><p class=\"msword-table-footnote\"> <sup class=\"msword-footnote-reference\"> a </sup> The federal reimbursement category code \"03\" was previously a valid value used by some states on claims for their ACA adult expansion population. However, <a id=\"_Hlk103946431\"></a> CMS retired the \"03\" value in September 2020 and states are expected to use the \"01\" value for this population moving forward since the enhanced match rate for these enrollees is authorized under Title XIX.</p><p class=\"msword-paragraph\"> If states are populating these data elements correctly, claim records that link to beneficiaries enrolled in Title XIX Medicaid will be coded to indicate the expenditure is reportable on Form CMS-64. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-3\" id=\"footnote-ref-3\">[2]</a> </sup> </sup> Similarly, claim records that link to beneficiaries enrolled in Title XXI CHIP&mdash;including both M-CHIP and S-CHIP programs&mdash;will be coded to indicate the expenditure is reportable on Form CMS-21.</p><p class=\"msword-paragraph\"> Other TAF data elements can be used to summarize Medicaid and CHIP spending associated with certain services or benefit categories, including the state-assigned type of service code, the federally-assigned service category code, and the benefit type code. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-4\" id=\"footnote-ref-4\">[3]</a> </sup> </sup> However, those data elements will not necessarily line up with the CMS-64 or CMS-21 categories that states use to report expenditures for the purposes of federal reimbursement.</p><p class=\"msword-paragraph\"> In this data quality assessment, we evaluate the percentage of records in each claims file reported with a federal reimbursement category code that is consistent with the beneficiary&rsquo;s enrollment in the Medicaid or CHIP programs. We also evaluate the percentage of records in each claims file reported with a CMS-64 or CMS-21 category of service code consistent with the beneficiary&rsquo;s enrollment in the Medicaid or CHIP program.</p><ol> <li class=\"footnoteBody\" id=\"footnote-2\" value=\"1\"> <p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page, and a crosswalk of variable names can be found in the guide &ldquo;Production of the TAF Research Identifiable Files.&rdquo; </p> <p> <a href=\"#footnote-ref-2\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-3\" value=\"2\"> <p class=\"msword-footnote-text\"> More information about differences between expenditures in the TAF and the CMS-64 data can be found in the DQ Atlas single topic displays under the Expenditure Benchmarking topic area. </p> <p> <a href=\"#footnote-ref-3\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-4\" value=\"3\"> <p class=\"msword-footnote-text\"> More information on states with missing or invalid type of service code can be found in the DQ Atlas single topic displays for <a aria-label=\"View DQ Atlas single topic display for Type of Service - IP\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m52\">Type of Service - IP</a> , <a aria-label=\"View DQ Atlas single topic display for Type of Service - OT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m53\">Type of Service - OT</a> , <a aria-label=\"View DQ Atlas single topic display for Type of Service - LT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m54\">Type of Service - LT</a> , and <a aria-label=\"View DQ Atlas single topic display for Type of Service - RX\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m55\">Type of Service - RX</a> . For more information about the FASC code, see the methodology brief, &ldquo;Assigning TAF Records to a Federally Assigned Service Category,&rdquo; on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page. </p> <p> <a href=\"#footnote-ref-4\">&uarr;</a> </p> </li></ol>", "footnotes": [{"number": 2, "content": "<li class=\"footnoteBody\" id=\"footnote-2\" value=\"1\"><p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page, and a crosswalk of variable names can be found in the guide \u201cProduction of the TAF Research Identifiable Files.\u201d </p><p><a href=\"#footnote-ref-2\">\u2191</a></p></li>"}, {"number": 3, "content": "<li class=\"footnoteBody\" id=\"footnote-3\" value=\"2\"><p class=\"msword-footnote-text\"> More information about differences between expenditures in the TAF and the CMS-64 data can be found in the DQ Atlas single topic displays under the Expenditure Benchmarking topic area. </p><p><a href=\"#footnote-ref-3\">\u2191</a></p></li>"}, {"number": 4, "content": "<li class=\"footnoteBody\" id=\"footnote-4\" value=\"3\"><p class=\"msword-footnote-text\"> More information on states with missing or invalid type of service code can be found in the DQ Atlas single topic displays for <a aria-label=\"View DQ Atlas single topic display for Type of Service - IP\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m52\">Type of Service - IP</a> , <a aria-label=\"View DQ Atlas single topic display for Type of Service - OT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m53\">Type of Service - OT</a> , <a aria-label=\"View DQ Atlas single topic display for Type of Service - LT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m54\">Type of Service - LT</a> , and <a aria-label=\"View DQ Atlas single topic display for Type of Service - RX\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m55\">Type of Service - RX</a> . For more information about the FASC code, see the methodology brief, \u201cAssigning TAF Records to a Federally Assigned Service Category,\u201d on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page. </p><p><a href=\"#footnote-ref-4\">\u2191</a></p></li>"}]}, "methods": {"content": "<p class=\"msword-paragraph\"> We began by selecting all records from the IP, LT, OT, and RX claims files that represented Medicaid and S-CHIP fee-for-service (FFS), capitation, and supplemental payments based on the claim type code. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-2\" id=\"footnote-ref-2\">[4]</a> </sup> </sup> <sup> , </sup> <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-3\" id=\"footnote-ref-3\">[5]</a> </sup> </sup> We excluded managed care encounter records from the analysis because the payments recorded on those claims do not represent state expenditures and are not recorded on the CMS-64 or CMS-21. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-4\" id=\"footnote-ref-4\">[6]</a> </sup> </sup> We also excluded service tracking claims from the analysis because these records are lump-sum payments that that cannot be linked to an eligibility record. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-5\" id=\"footnote-ref-5\">[7]</a> </sup> </sup></p><p class=\"msword-paragraph\"> To determine whether the beneficiary was enrolled in Medicaid, M-CHIP, or S-CHIP on the date of service, we linked the claims records to the matching eligibility record using the unique beneficiary identifier coded on the claim (MSIS ID). We determined Medicaid, M-CHIP, and S-CHIP enrollment by examining the CHIP code on records in the TAF Demographic and Eligibility (DE) file from the month that corresponded to the date of service on the claim. We excluded from the analysis claims records with a missing or invalid beneficiary identifier. Additionally, we excluded claims that did not link to an eligibility record, as well as those that linked to an eligibility record but did not have a CHIP code populated (indicating the individual was enrolled in Medicaid or CHIP) during the date of service on the claim. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-6\" id=\"footnote-ref-6\">[8]</a> </sup> </sup></p><p class=\"msword-paragraph\"> Finally, we calculated the percentage of records in each file with a federal reimbursement category code consistent with the beneficiary&rsquo;s reported enrollment in Medicaid, M-CHIP, or S-CHIP. The expected coding for federal reimbursement category code based on CHIP code is shown in Table 2. Because Medicaid beneficiaries enrolled in an adult expansion eligibility group may have a different federal reimbursement category code than Medicaid beneficiaries not enrolled in such a group, we examined these two groups of Medicaid beneficiaries separately. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-7\" id=\"footnote-ref-7\">[9]</a> </sup> </sup> We also calculated the percentage of records with a CMS-64 or CMS-21 category of service code consistent with the beneficiary&rsquo;s enrollment in the Medicaid or CHIP program. The expected coding for CMS-64 and CMS-21 category of service code based on CHIP code is shown in Table 3.</p><p class=\"msword-table-title\"> Table 2. Expected coding for federal reimbursement category code</p><table aria-label=\"Table 2. Expected coding for federal reimbursement category code\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Enrollment type </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> CHIP code on eligibility record (CHIP_CD) </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Latest eligibility group on eligibility record (ELGBLTY_GRP_CD_LTST) </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Expected federal reimbursement category code on claim record </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Medicaid &ndash; Adult expansion group </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 1 </strong> (Medicaid) </p> </td> <td> <p class=\"msword-table-text-centered\"> <strong> 72 </strong> (Adult Group - Individuals at or below 133% FPL Age 19 through 64 - newly eligible for all states) </p> <p class=\"msword-table-text-centered\"> <strong> 73 </strong> (Adult Group - Individuals at or below 133% FPL Age 19 through 64- not newly eligible for non 1905z(3) states), </p> <p class=\"msword-table-text-centered\"> <strong> 74 </strong> (Adult Group - Individuals at or below 133% FPL Age 19 through 64 &ndash; not newly eligible parent/ caretaker relative(s) in 1905z(3) states), or </p> <p class=\"msword-table-text-centered\"> <strong> 75 </strong> (Adult Group - Individuals at or below 133% FPL Age 19 through 64- not newly eligible non-parent/ caretaker-relative(s) in 1905z(3) states) </p> </td> <td> <p class=\"msword-table-text-centered\"> <strong> 01 </strong> (Federal funding under Title XIX) or </p> <p class=\"msword-table-text-centered\"> <strong> 03 </strong> (Federal funding under ACA) <sup class=\"msword-superscript\"> a </sup> </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Medicaid &ndash; All other </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 1 </strong> (Medicaid) </p> </td> <td> <p class=\"msword-table-text-centered\"> Any valid code or null/missing, except: </p> <p class=\"msword-table-text-centered\"> <strong> 72, 73, 74, 75, </strong> or </p> <p class=\"msword-table-text-centered\"> <strong> 61-68 </strong> (CHIP eligibility groups) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 01 </strong> (Federal funding under Title XIX) </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> M-CHIP </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 2 </strong> (M-CHIP) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> N/A </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 02 </strong> (Federal funding under Title XXI) </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> S-CHIP </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 3 </strong> (S-CHIP) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> N/A </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 02 </strong> (Federal funding under Title XXI) </p> </td> </tr> </tbody></table><p class=\"msword-table-footnote\"> <sup class=\"msword-footnote-reference\"> a </sup> In this assessment, we consider both \"01\" and \"03\" to be consistent values for Medicaid-enrolled beneficiaries in the adult expansion eligibility groups. The value \"03\" (Federal funding under ACA) was retired as a valid value on September 30, 2020 and while the value is still present in the data before that date, we would expect to see relatively few claims with this value after that date.</p><p class=\"msword-table-footnote\"> ACA = Affordable Care Act; FPL = Federal Poverty Level; N/A = not available.</p><p class=\"msword-table-title\"> Table 3. Expected coding for CMS-64 and CMS-21 category of service codes</p><table aria-label=\"Table 3. Expected coding for CMS-64 and CMS-21 category of service codes\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> CHIP code on eligibility record (CHIP_CD) </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Expected CMS-64 category of service code on claims record </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Expected CMS-21 category of service code on claims record </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> <strong> 1 </strong> (Medicaid) </p> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> Any valid value for CMS-64 category of service </li> </ul> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> Field should be blank </li> </ul> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> <strong> 2 </strong> (M-CHIP) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Field should be blank </p> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> Any valid value for CMS-21 category of service </li> </ul> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> <strong> 3 </strong> (S-CHIP) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Field should be blank </p> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> Any valid value for CMS-21 category of service </li> </ul> </td> </tr> </tbody></table><p class=\"msword-header\"> Data quality assessment criteria</p><p class=\"msword-paragraph\"> We categorized each state as having low, medium, or high data quality concern for the federal reimbursement category code, depending on the percentage of records with a federal reimbursement category code consistent with the beneficiary&rsquo;s enrollment in the Medicaid, M-CHIP, or S-CHIP programs, as shown in Table 4.</p><p class=\"msword-table-title\"> Table 4. Criteria for DQ assessment of federal reimbursement category code</p><table aria-label=\"Table 4. Criteria for DQ assessment of federal reimbursement category code\" class=\"dq-assessment-table\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Percentage of claim lines with a federal reimbursement category code consistent with program enrollment </p> </th> <th class=\"msword-table-header-center dq-assessment-col\"> <p class=\"msword-table-header-center\"> DQ assessment </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &ge; 90 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level low\"> <p class=\"msword-table-text-centered\"> Low concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 80 percent &le; x &lt; 90 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level medium\"> <p class=\"msword-table-text-centered\"> Medium concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 50 percent &le; x &lt; 80 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level high\"> <p class=\"msword-table-text-centered\"> High concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &lt; 50 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level unusable\"> <p class=\"msword-table-text-centered\"> Unusable </p> </td> </tr> </tbody></table><p class=\"msword-paragraph\"> We categorized each state as having low, medium, or high data quality concern for the category of service code, depending on the percentage of records with a CMS-64 or CMS-21 category of service code consistent with the beneficiary&rsquo;s enrollment in the Medicaid, M-CHIP, or S-CHIP programs, as shown in Table 5. As shown in Table 3, only the CMS-64 or CMS-21 category of service code is expected to be populated on a single claim record. When both fields were populated on the same claim (even if one or both values were invalid), that record was inconsistent with enrollment in the Medicaid, M-CHIP, or S-CHIP programs for the purposes of this analysis.</p><p class=\"msword-table-title\"> Table 5. Criteria for DQ assessment of category of service codes</p><table aria-label=\"Table 5. Criteria for DQ assessment of category of service codes\" class=\"dq-assessment-table\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Percentage of claim lines with a CMS-64 category of service code or a CMS-21 category of service code consistent with program enrollment </p> </th> <th class=\"msword-table-header-center dq-assessment-col\"> <p class=\"msword-table-header-center\"> DQ assessment </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &ge; 90 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level low\"> <p class=\"msword-table-text-centered\"> Low concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 80 percent &le; x &lt; 90 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level medium\"> <p class=\"msword-table-text-centered\"> Medium concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 50 percent &le; x &lt; 80 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level high\"> <p class=\"msword-table-text-centered\"> High concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &lt; 50 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level unusable\"> <p class=\"msword-table-text-centered\"> Unusable </p> </td> </tr> </tbody></table><ol> <li class=\"footnoteBody\" id=\"footnote-2\" value=\"4\"> <p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page, and a crosswalk of variable names can be found in the guide &ldquo;Production of the TAF Research Identifiable Files.&rdquo; </p> <p> <a href=\"#footnote-ref-2\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-3\" value=\"5\"> <p class=\"msword-footnote-text\"> FFS claims representing Medicaid or M-CHIP services have a claim type code (CLM_TYPE_CD) value of 1, capitation payments have a claim type code value of 2, and supplemental payments have a claim type code value of 5. FFS claims representing S-CHIP benefits have a claim type code value of A, capitation payments have a claim type code value of B, and supplemental payments have a claim type code value of E. </p> <p> <a href=\"#footnote-ref-3\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-4\" value=\"6\"> <p class=\"msword-footnote-text\"> Payment data on managed care encounter records are redacted from the TAF RIFs. </p> <p> <a href=\"#footnote-ref-4\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-5\" value=\"7\"> <p class=\"msword-footnote-text\"> Managed care encounter records representing Medicaid or M-CHIP services have a claim type code value of 3 and service tracking claims have a claim type code value of 4. Managed care encounter records representing S-CHIP benefits have a claim type code value of C, and service tracking claims have a claim type code value of D. </p> <p> <a href=\"#footnote-ref-5\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-6\" value=\"8\"> <p class=\"msword-footnote-text\"> Once an individual is determined eligible for Medicaid, coverage is effective either on the date of application or the first day of the month of application. Benefits also may be covered retroactively for up to three months prior to the month of application if the individual would have been eligible during that period had he or she applied. States are required to update beneficiaries&rsquo; eligibility records in T-MSIS to reflect the retroactive coverage period. However, if a state did not update the eligibility record of a beneficiary to reflect the retroactive coverage period, enrollment information like CHIP code may be missing during the date of service on a paid claim. </p> <p> <a href=\"#footnote-ref-6\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-7\" value=\"9\"> <p class=\"msword-footnote-text\"> We determined the eligibility group by using ELGBLTY_GRP_CD_LTST, the most recent eligibility group reported for the beneficiary in the calendar year. </p> <p> <a href=\"#footnote-ref-7\">&uarr;</a> </p> </li></ol>", "footnotes": [{"number": 2, "content": "<li class=\"footnoteBody\" id=\"footnote-2\" value=\"4\"><p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page, and a crosswalk of variable names can be found in the guide \u201cProduction of the TAF Research Identifiable Files.\u201d </p><p><a href=\"#footnote-ref-2\">\u2191</a></p></li>"}, {"number": 3, "content": "<li class=\"footnoteBody\" id=\"footnote-3\" value=\"5\"><p class=\"msword-footnote-text\"> FFS claims representing Medicaid or M-CHIP services have a claim type code (CLM_TYPE_CD) value of 1, capitation payments have a claim type code value of 2, and supplemental payments have a claim type code value of 5. FFS claims representing S-CHIP benefits have a claim type code value of A, capitation payments have a claim type code value of B, and supplemental payments have a claim type code value of E. </p><p><a href=\"#footnote-ref-3\">\u2191</a></p></li>"}, {"number": 4, "content": "<li class=\"footnoteBody\" id=\"footnote-4\" value=\"6\"><p class=\"msword-footnote-text\"> Payment data on managed care encounter records are redacted from the TAF RIFs. </p><p><a href=\"#footnote-ref-4\">\u2191</a></p></li>"}, {"number": 5, "content": "<li class=\"footnoteBody\" id=\"footnote-5\" value=\"7\"><p class=\"msword-footnote-text\"> Managed care encounter records representing Medicaid or M-CHIP services have a claim type code value of 3 and service tracking claims have a claim type code value of 4. Managed care encounter records representing S-CHIP benefits have a claim type code value of C, and service tracking claims have a claim type code value of D. </p><p><a href=\"#footnote-ref-5\">\u2191</a></p></li>"}, {"number": 6, "content": "<li class=\"footnoteBody\" id=\"footnote-6\" value=\"8\"><p class=\"msword-footnote-text\"> Once an individual is determined eligible for Medicaid, coverage is effective either on the date of application or the first day of the month of application. Benefits also may be covered retroactively for up to three months prior to the month of application if the individual would have been eligible during that period had he or she applied. States are required to update beneficiaries\u2019 eligibility records in T-MSIS to reflect the retroactive coverage period. However, if a state did not update the eligibility record of a beneficiary to reflect the retroactive coverage period, enrollment information like CHIP code may be missing during the date of service on a paid claim. </p><p><a href=\"#footnote-ref-6\">\u2191</a></p></li>"}, {"number": 7, "content": "<li class=\"footnoteBody\" id=\"footnote-7\" value=\"9\"><p class=\"msword-footnote-text\"> We determined the eligibility group by using ELGBLTY_GRP_CD_LTST, the most recent eligibility group reported for the beneficiary in the calendar year. </p><p><a href=\"#footnote-ref-7\">\u2191</a></p></li>"}]}, "summary": {"content": "<p>States report quarterly Medicaid expenditures on Form CMS-64 and quarterly Children's Health Insurance Program (CHIP) expenditures on Form CMS-21 to claim federal matching funds. In the T-MSIS Analytic Files (TAF), the CMS-64 category of service code data element on paid claim records should reflect the category where expenditures for the service are reported on Form CMS-64. Similarly, the CMS-21 category of service code on a paid claim record should reflect the category where expenditures for the service are reported on Form CMS-21. This analysis examines the extent to which records in the OT file are reported with a CMS-64 or CMS-21 category of service code value consistent with the beneficiary's enrollment in the Medicaid or CHIP program.</p>", "footnotes": []}, "originalIssueBriefId": "5221", "relatedTopics": [{"measureId": 111, "measureName": "Category of Service Code - IP", "groupId": 12, "groupName": "Financial Reporting", "order": 0}, {"measureId": 112, "measureName": "Category of Service Code - LT", "groupId": 12, "groupName": "Financial Reporting", "order": 1}, {"measureId": 114, "measureName": "Category of Service Code - RX", "groupId": 12, "groupName": "Financial Reporting", "order": 3}, {"measureId": 115, "measureName": "Federal Reimbursement Category Code - IP", "groupId": 12, "groupName": "Financial Reporting", "order": 4}, {"measureId": 116, "measureName": "Federal Reimbursement Category Code - LT", "groupId": 12, "groupName": "Financial Reporting", "order": 5}, {"measureId": 117, "measureName": "Federal Reimbursement Category Code - OT", "groupId": 12, "groupName": "Financial Reporting", "order": 6}, {"measureId": 118, "measureName": "Federal Reimbursement Category Code - RX", "groupId": 12, "groupName": "Financial Reporting", "order": 7}]}
114
{"measureId": 114, "measureName": "Category of Service Code - RX", "groupId": 12, "groupName": "Financial Reporting", "pdfVersionLink": "downloads/background-and-methods/TAF-DQ-Srvc-Cat-Cd-RX.pdf", "background": {"content": "<p class=\"msword-paragraph\"> <a id=\"_Hlk30592933\"></a> <a id=\"_Hlk95402275\"></a> Medicaid and the Children&rsquo;s Health Insurance Program (CHIP) are joint state-federal medical assistance programs in which the state administers the program and pays providers or health plans directly for covered services, and the federal government reimburses a set percentage of the state&rsquo;s expenditures (referred to as the \"federal match\"). Because the federal government applies different federal matching rates to Medicaid and CHIP beneficiaries, states report Medicaid and CHIP expenditure data separately.</p><p class=\"msword-paragraph\"> To claim federal matching funds for their medical assistance programs, states report aggregate expenditure data for Medicaid beneficiaries covered under Title XIX of the Social Security Act to the Centers for Medicare &amp; Medicaid Services (CMS) on Form CMS-64, <em> Quarterly Medicaid Statement of Expenditures. </em> States report aggregate expenditure data for the CHIP beneficiaries covered under Title XXI of the Social Security Act on Form CMS-21, <em> Quarterly CHIP Statement of Expenditures </em> . States may cover children using CHIP funds by expanding their Medicaid programs (called \"Medicaid expansion CHIP,\" or M-CHIP), creating a program separate from their existing Medicaid programs (called \"separate CHIP,\" or S-CHIP), or adopting a combination of both approaches. Expenditures for both M-CHIP and S-CHIP beneficiaries, which qualify for the higher CHIP federal match rate, are reported on Form CMS-21 and not Form CMS-64.</p><p class=\"msword-paragraph\"> There are three data elements in the T-MSIS Analytic Files (TAF) inpatient (IP), long-term care (LT), other services (OT), and pharmacy (RX) files that contain information about how states report Medicaid and CHIP expenditures to claim federal matching funds: the federal reimbursement category code, the CMS-64 category of service code, and the CMS-21 category of service code (Table 1). <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-2\" id=\"footnote-ref-2\">[1]</a> </sup> </sup> The federal reimbursement category code indicates whether the expenditure was reimbursed under Title XIX, Title XXI, the Affordable Care Act (ACA), or other legislation. As noted earlier, if the expenditure was covered by Title XIX of the Social Security Act, it should be reported on Form CMS-64; if the expenditure was covered by Title XXI of the Social Security Act it should be reported on Form CMS-21. The CMS-64 category of service code indicates the specific category of service on Form CMS-64 into which the state will report the Medicaid expenditures associated with a paid claim. The CMS-21 category of service code indicates the specific category of service on Form CMS-21 into which the state will report the CHIP expenditures associated with a paid claim.</p><p class=\"msword-table-title\"> Table 1. TAF variables that classify expenditures into federal reimbursement categories</p><table aria-label=\"Table 1. TAF variables that classify expenditures into federal reimbursement categories\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Variable </p> </th> <th> <p class=\"msword-table-header-center\"> TAF data element name </p> <p class=\"msword-table-header-center\"> (TAF RIF name in parentheses if different) </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> IP, LT, OT, and RX records expected to have non-missing values </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Description </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Federal reimbursement category code </p> </td> <td> <p class=\"msword-table-text-centered\"> CMS_64_FED_REIMBRSMT_CTGRY_CD </p> <p class=\"msword-table-text-centered\"> (CMS_64_FED_CTGRY_CD) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> All records </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> This code indicates whether the claim was matched with federal funding under Title XIX (value of &lsquo;01&rsquo;), Title XXI (&lsquo;02&rsquo;), the Affordable Care Act (&lsquo;03&rsquo;), <sup class=\"msword-superscript\"> a </sup> or federal funding under other legislation (&lsquo;04&rsquo;). </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> CMS-64 category of service code </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> XIX_SRVC_CTGRY_CD </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Only records representing expenditures that the state will report on the CMS-64, which should link to beneficiaries enrolled in non-CHIP Medicaid </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> A four-digit code (from 001A to 0050) indicating the line on the Form CMS-64 on which the state reported the expenditures associated with the claim. The Form CMS-64 is used to report expenditures that qualify for federal matching funds under Title XXI. A full list of the category of service and definition for each line can be found at <a aria-label=\"View Categories of service in the CMS-64 on Medicaid.gov\" href=\"https://www.medicaid.gov/medicaid/downloads/cms-649-base-category-of-services-definition-2-14.pdf\">https://www.medicaid.gov/medicaid/downloads/cms-649-base-category-of-services-definition-2-14.pdf</a> . </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> CMS-21 category of service code </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> XIX_SRVC_CTGRY_CD </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Only records representing expenditures that the state will report on the CMS-21, which should link to beneficiaries enrolled in Medicaid-expansion CHIP or Separate CHIP </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> A three-digit code (from 01A to 35B) indicating the category of service (or line) on the Form CMS-21 on which the state reported the expenditures associated with the claim. The Form CMS-21 is used to report expenditures that qualify for federal matching funds under Title XXI. A full list of the category of service and definition for each line can be found at <a aria-label=\"View MBES Category of Service Definitions for the CMS-21 Base Form\" href=\"https://www.medicaid.gov/medicaid/downloads/cms-21-base-category-of-services-definition-2-14.pdf\">https://www.medicaid.gov/medicaid/downloads/cms-21-base-category-of-services-definition-2-14.pdf</a> . </p> </td> </tr> </tbody></table><p class=\"msword-table-footnote\"> <sup class=\"msword-footnote-reference\"> a </sup> The federal reimbursement category code \"03\" was previously a valid value used by some states on claims for their ACA adult expansion population. However, <a id=\"_Hlk103946431\"></a> CMS retired the \"03\" value in September 2020 and states are expected to use the \"01\" value for this population moving forward since the enhanced match rate for these enrollees is authorized under Title XIX.</p><p class=\"msword-paragraph\"> If states are populating these data elements correctly, claim records that link to beneficiaries enrolled in Title XIX Medicaid will be coded to indicate the expenditure is reportable on Form CMS-64. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-3\" id=\"footnote-ref-3\">[2]</a> </sup> </sup> Similarly, claim records that link to beneficiaries enrolled in Title XXI CHIP&mdash;including both M-CHIP and S-CHIP programs&mdash;will be coded to indicate the expenditure is reportable on Form CMS-21.</p><p class=\"msword-paragraph\"> Other TAF data elements can be used to summarize Medicaid and CHIP spending associated with certain services or benefit categories, including the state-assigned type of service code, the federally-assigned service category code, and the benefit type code. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-4\" id=\"footnote-ref-4\">[3]</a> </sup> </sup> However, those data elements will not necessarily line up with the CMS-64 or CMS-21 categories that states use to report expenditures for the purposes of federal reimbursement.</p><p class=\"msword-paragraph\"> In this data quality assessment, we evaluate the percentage of records in each claims file reported with a federal reimbursement category code that is consistent with the beneficiary&rsquo;s enrollment in the Medicaid or CHIP programs. We also evaluate the percentage of records in each claims file reported with a CMS-64 or CMS-21 category of service code consistent with the beneficiary&rsquo;s enrollment in the Medicaid or CHIP program.</p><ol> <li class=\"footnoteBody\" id=\"footnote-2\" value=\"1\"> <p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page, and a crosswalk of variable names can be found in the guide &ldquo;Production of the TAF Research Identifiable Files.&rdquo; </p> <p> <a href=\"#footnote-ref-2\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-3\" value=\"2\"> <p class=\"msword-footnote-text\"> More information about differences between expenditures in the TAF and the CMS-64 data can be found in the DQ Atlas single topic displays under the Expenditure Benchmarking topic area. </p> <p> <a href=\"#footnote-ref-3\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-4\" value=\"3\"> <p class=\"msword-footnote-text\"> More information on states with missing or invalid type of service code can be found in the DQ Atlas single topic displays for <a aria-label=\"View DQ Atlas single topic display for Type of Service - IP\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m52\">Type of Service - IP</a> , <a aria-label=\"View DQ Atlas single topic display for Type of Service - OT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m53\">Type of Service - OT</a> , <a aria-label=\"View DQ Atlas single topic display for Type of Service - LT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m54\">Type of Service - LT</a> , and <a aria-label=\"View DQ Atlas single topic display for Type of Service - RX\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m55\">Type of Service - RX</a> . For more information about the FASC code, see the methodology brief, &ldquo;Assigning TAF Records to a Federally Assigned Service Category,&rdquo; on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page. </p> <p> <a href=\"#footnote-ref-4\">&uarr;</a> </p> </li></ol>", "footnotes": [{"number": 2, "content": "<li class=\"footnoteBody\" id=\"footnote-2\" value=\"1\"><p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page, and a crosswalk of variable names can be found in the guide \u201cProduction of the TAF Research Identifiable Files.\u201d </p><p><a href=\"#footnote-ref-2\">\u2191</a></p></li>"}, {"number": 3, "content": "<li class=\"footnoteBody\" id=\"footnote-3\" value=\"2\"><p class=\"msword-footnote-text\"> More information about differences between expenditures in the TAF and the CMS-64 data can be found in the DQ Atlas single topic displays under the Expenditure Benchmarking topic area. </p><p><a href=\"#footnote-ref-3\">\u2191</a></p></li>"}, {"number": 4, "content": "<li class=\"footnoteBody\" id=\"footnote-4\" value=\"3\"><p class=\"msword-footnote-text\"> More information on states with missing or invalid type of service code can be found in the DQ Atlas single topic displays for <a aria-label=\"View DQ Atlas single topic display for Type of Service - IP\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m52\">Type of Service - IP</a> , <a aria-label=\"View DQ Atlas single topic display for Type of Service - OT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m53\">Type of Service - OT</a> , <a aria-label=\"View DQ Atlas single topic display for Type of Service - LT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m54\">Type of Service - LT</a> , and <a aria-label=\"View DQ Atlas single topic display for Type of Service - RX\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m55\">Type of Service - RX</a> . For more information about the FASC code, see the methodology brief, \u201cAssigning TAF Records to a Federally Assigned Service Category,\u201d on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page. </p><p><a href=\"#footnote-ref-4\">\u2191</a></p></li>"}]}, "methods": {"content": "<p class=\"msword-paragraph\"> We began by selecting all records from the IP, LT, OT, and RX claims files that represented Medicaid and S-CHIP fee-for-service (FFS), capitation, and supplemental payments based on the claim type code. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-2\" id=\"footnote-ref-2\">[4]</a> </sup> </sup> <sup> , </sup> <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-3\" id=\"footnote-ref-3\">[5]</a> </sup> </sup> We excluded managed care encounter records from the analysis because the payments recorded on those claims do not represent state expenditures and are not recorded on the CMS-64 or CMS-21. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-4\" id=\"footnote-ref-4\">[6]</a> </sup> </sup> We also excluded service tracking claims from the analysis because these records are lump-sum payments that that cannot be linked to an eligibility record. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-5\" id=\"footnote-ref-5\">[7]</a> </sup> </sup></p><p class=\"msword-paragraph\"> To determine whether the beneficiary was enrolled in Medicaid, M-CHIP, or S-CHIP on the date of service, we linked the claims records to the matching eligibility record using the unique beneficiary identifier coded on the claim (MSIS ID). We determined Medicaid, M-CHIP, and S-CHIP enrollment by examining the CHIP code on records in the TAF Demographic and Eligibility (DE) file from the month that corresponded to the date of service on the claim. We excluded from the analysis claims records with a missing or invalid beneficiary identifier. Additionally, we excluded claims that did not link to an eligibility record, as well as those that linked to an eligibility record but did not have a CHIP code populated (indicating the individual was enrolled in Medicaid or CHIP) during the date of service on the claim. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-6\" id=\"footnote-ref-6\">[8]</a> </sup> </sup></p><p class=\"msword-paragraph\"> Finally, we calculated the percentage of records in each file with a federal reimbursement category code consistent with the beneficiary&rsquo;s reported enrollment in Medicaid, M-CHIP, or S-CHIP. The expected coding for federal reimbursement category code based on CHIP code is shown in Table 2. Because Medicaid beneficiaries enrolled in an adult expansion eligibility group may have a different federal reimbursement category code than Medicaid beneficiaries not enrolled in such a group, we examined these two groups of Medicaid beneficiaries separately. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-7\" id=\"footnote-ref-7\">[9]</a> </sup> </sup> We also calculated the percentage of records with a CMS-64 or CMS-21 category of service code consistent with the beneficiary&rsquo;s enrollment in the Medicaid or CHIP program. The expected coding for CMS-64 and CMS-21 category of service code based on CHIP code is shown in Table 3.</p><p class=\"msword-table-title\"> Table 2. Expected coding for federal reimbursement category code</p><table aria-label=\"Table 2. Expected coding for federal reimbursement category code\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Enrollment type </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> CHIP code on eligibility record (CHIP_CD) </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Latest eligibility group on eligibility record (ELGBLTY_GRP_CD_LTST) </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Expected federal reimbursement category code on claim record </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Medicaid &ndash; Adult expansion group </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 1 </strong> (Medicaid) </p> </td> <td> <p class=\"msword-table-text-centered\"> <strong> 72 </strong> (Adult Group - Individuals at or below 133% FPL Age 19 through 64 - newly eligible for all states) </p> <p class=\"msword-table-text-centered\"> <strong> 73 </strong> (Adult Group - Individuals at or below 133% FPL Age 19 through 64- not newly eligible for non 1905z(3) states), </p> <p class=\"msword-table-text-centered\"> <strong> 74 </strong> (Adult Group - Individuals at or below 133% FPL Age 19 through 64 &ndash; not newly eligible parent/ caretaker relative(s) in 1905z(3) states), or </p> <p class=\"msword-table-text-centered\"> <strong> 75 </strong> (Adult Group - Individuals at or below 133% FPL Age 19 through 64- not newly eligible non-parent/ caretaker-relative(s) in 1905z(3) states) </p> </td> <td> <p class=\"msword-table-text-centered\"> <strong> 01 </strong> (Federal funding under Title XIX) or </p> <p class=\"msword-table-text-centered\"> <strong> 03 </strong> (Federal funding under ACA) <sup class=\"msword-superscript\"> a </sup> </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Medicaid &ndash; All other </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 1 </strong> (Medicaid) </p> </td> <td> <p class=\"msword-table-text-centered\"> Any valid code or null/missing, except: </p> <p class=\"msword-table-text-centered\"> <strong> 72, 73, 74, 75, </strong> or </p> <p class=\"msword-table-text-centered\"> <strong> 61-68 </strong> (CHIP eligibility groups) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 01 </strong> (Federal funding under Title XIX) </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> M-CHIP </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 2 </strong> (M-CHIP) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> N/A </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 02 </strong> (Federal funding under Title XXI) </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> S-CHIP </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 3 </strong> (S-CHIP) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> N/A </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 02 </strong> (Federal funding under Title XXI) </p> </td> </tr> </tbody></table><p class=\"msword-table-footnote\"> <sup class=\"msword-footnote-reference\"> a </sup> In this assessment, we consider both \"01\" and \"03\" to be consistent values for Medicaid-enrolled beneficiaries in the adult expansion eligibility groups. The value \"03\" (Federal funding under ACA) was retired as a valid value on September 30, 2020 and while the value is still present in the data before that date, we would expect to see relatively few claims with this value after that date.</p><p class=\"msword-table-footnote\"> ACA = Affordable Care Act; FPL = Federal Poverty Level; N/A = not available.</p><p class=\"msword-table-title\"> Table 3. Expected coding for CMS-64 and CMS-21 category of service codes</p><table aria-label=\"Table 3. Expected coding for CMS-64 and CMS-21 category of service codes\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> CHIP code on eligibility record (CHIP_CD) </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Expected CMS-64 category of service code on claims record </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Expected CMS-21 category of service code on claims record </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> <strong> 1 </strong> (Medicaid) </p> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> Any valid value for CMS-64 category of service </li> </ul> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> Field should be blank </li> </ul> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> <strong> 2 </strong> (M-CHIP) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Field should be blank </p> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> Any valid value for CMS-21 category of service </li> </ul> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> <strong> 3 </strong> (S-CHIP) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Field should be blank </p> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> Any valid value for CMS-21 category of service </li> </ul> </td> </tr> </tbody></table><p class=\"msword-header\"> Data quality assessment criteria</p><p class=\"msword-paragraph\"> We categorized each state as having low, medium, or high data quality concern for the federal reimbursement category code, depending on the percentage of records with a federal reimbursement category code consistent with the beneficiary&rsquo;s enrollment in the Medicaid, M-CHIP, or S-CHIP programs, as shown in Table 4.</p><p class=\"msword-table-title\"> Table 4. Criteria for DQ assessment of federal reimbursement category code</p><table aria-label=\"Table 4. Criteria for DQ assessment of federal reimbursement category code\" class=\"dq-assessment-table\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Percentage of claim lines with a federal reimbursement category code consistent with program enrollment </p> </th> <th class=\"msword-table-header-center dq-assessment-col\"> <p class=\"msword-table-header-center\"> DQ assessment </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &ge; 90 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level low\"> <p class=\"msword-table-text-centered\"> Low concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 80 percent &le; x &lt; 90 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level medium\"> <p class=\"msword-table-text-centered\"> Medium concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 50 percent &le; x &lt; 80 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level high\"> <p class=\"msword-table-text-centered\"> High concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &lt; 50 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level unusable\"> <p class=\"msword-table-text-centered\"> Unusable </p> </td> </tr> </tbody></table><p class=\"msword-paragraph\"> We categorized each state as having low, medium, or high data quality concern for the category of service code, depending on the percentage of records with a CMS-64 or CMS-21 category of service code consistent with the beneficiary&rsquo;s enrollment in the Medicaid, M-CHIP, or S-CHIP programs, as shown in Table 5. As shown in Table 3, only the CMS-64 or CMS-21 category of service code is expected to be populated on a single claim record. When both fields were populated on the same claim (even if one or both values were invalid), that record was inconsistent with enrollment in the Medicaid, M-CHIP, or S-CHIP programs for the purposes of this analysis.</p><p class=\"msword-table-title\"> Table 5. Criteria for DQ assessment of category of service codes</p><table aria-label=\"Table 5. Criteria for DQ assessment of category of service codes\" class=\"dq-assessment-table\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Percentage of claim lines with a CMS-64 category of service code or a CMS-21 category of service code consistent with program enrollment </p> </th> <th class=\"msword-table-header-center dq-assessment-col\"> <p class=\"msword-table-header-center\"> DQ assessment </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &ge; 90 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level low\"> <p class=\"msword-table-text-centered\"> Low concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 80 percent &le; x &lt; 90 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level medium\"> <p class=\"msword-table-text-centered\"> Medium concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 50 percent &le; x &lt; 80 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level high\"> <p class=\"msword-table-text-centered\"> High concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &lt; 50 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level unusable\"> <p class=\"msword-table-text-centered\"> Unusable </p> </td> </tr> </tbody></table><ol> <li class=\"footnoteBody\" id=\"footnote-2\" value=\"4\"> <p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page, and a crosswalk of variable names can be found in the guide &ldquo;Production of the TAF Research Identifiable Files.&rdquo; </p> <p> <a href=\"#footnote-ref-2\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-3\" value=\"5\"> <p class=\"msword-footnote-text\"> FFS claims representing Medicaid or M-CHIP services have a claim type code (CLM_TYPE_CD) value of 1, capitation payments have a claim type code value of 2, and supplemental payments have a claim type code value of 5. FFS claims representing S-CHIP benefits have a claim type code value of A, capitation payments have a claim type code value of B, and supplemental payments have a claim type code value of E. </p> <p> <a href=\"#footnote-ref-3\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-4\" value=\"6\"> <p class=\"msword-footnote-text\"> Payment data on managed care encounter records are redacted from the TAF RIFs. </p> <p> <a href=\"#footnote-ref-4\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-5\" value=\"7\"> <p class=\"msword-footnote-text\"> Managed care encounter records representing Medicaid or M-CHIP services have a claim type code value of 3 and service tracking claims have a claim type code value of 4. Managed care encounter records representing S-CHIP benefits have a claim type code value of C, and service tracking claims have a claim type code value of D. </p> <p> <a href=\"#footnote-ref-5\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-6\" value=\"8\"> <p class=\"msword-footnote-text\"> Once an individual is determined eligible for Medicaid, coverage is effective either on the date of application or the first day of the month of application. Benefits also may be covered retroactively for up to three months prior to the month of application if the individual would have been eligible during that period had he or she applied. States are required to update beneficiaries&rsquo; eligibility records in T-MSIS to reflect the retroactive coverage period. However, if a state did not update the eligibility record of a beneficiary to reflect the retroactive coverage period, enrollment information like CHIP code may be missing during the date of service on a paid claim. </p> <p> <a href=\"#footnote-ref-6\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-7\" value=\"9\"> <p class=\"msword-footnote-text\"> We determined the eligibility group by using ELGBLTY_GRP_CD_LTST, the most recent eligibility group reported for the beneficiary in the calendar year. </p> <p> <a href=\"#footnote-ref-7\">&uarr;</a> </p> </li></ol>", "footnotes": [{"number": 2, "content": "<li class=\"footnoteBody\" id=\"footnote-2\" value=\"4\"><p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page, and a crosswalk of variable names can be found in the guide \u201cProduction of the TAF Research Identifiable Files.\u201d </p><p><a href=\"#footnote-ref-2\">\u2191</a></p></li>"}, {"number": 3, "content": "<li class=\"footnoteBody\" id=\"footnote-3\" value=\"5\"><p class=\"msword-footnote-text\"> FFS claims representing Medicaid or M-CHIP services have a claim type code (CLM_TYPE_CD) value of 1, capitation payments have a claim type code value of 2, and supplemental payments have a claim type code value of 5. FFS claims representing S-CHIP benefits have a claim type code value of A, capitation payments have a claim type code value of B, and supplemental payments have a claim type code value of E. </p><p><a href=\"#footnote-ref-3\">\u2191</a></p></li>"}, {"number": 4, "content": "<li class=\"footnoteBody\" id=\"footnote-4\" value=\"6\"><p class=\"msword-footnote-text\"> Payment data on managed care encounter records are redacted from the TAF RIFs. </p><p><a href=\"#footnote-ref-4\">\u2191</a></p></li>"}, {"number": 5, "content": "<li class=\"footnoteBody\" id=\"footnote-5\" value=\"7\"><p class=\"msword-footnote-text\"> Managed care encounter records representing Medicaid or M-CHIP services have a claim type code value of 3 and service tracking claims have a claim type code value of 4. Managed care encounter records representing S-CHIP benefits have a claim type code value of C, and service tracking claims have a claim type code value of D. </p><p><a href=\"#footnote-ref-5\">\u2191</a></p></li>"}, {"number": 6, "content": "<li class=\"footnoteBody\" id=\"footnote-6\" value=\"8\"><p class=\"msword-footnote-text\"> Once an individual is determined eligible for Medicaid, coverage is effective either on the date of application or the first day of the month of application. Benefits also may be covered retroactively for up to three months prior to the month of application if the individual would have been eligible during that period had he or she applied. States are required to update beneficiaries\u2019 eligibility records in T-MSIS to reflect the retroactive coverage period. However, if a state did not update the eligibility record of a beneficiary to reflect the retroactive coverage period, enrollment information like CHIP code may be missing during the date of service on a paid claim. </p><p><a href=\"#footnote-ref-6\">\u2191</a></p></li>"}, {"number": 7, "content": "<li class=\"footnoteBody\" id=\"footnote-7\" value=\"9\"><p class=\"msword-footnote-text\"> We determined the eligibility group by using ELGBLTY_GRP_CD_LTST, the most recent eligibility group reported for the beneficiary in the calendar year. </p><p><a href=\"#footnote-ref-7\">\u2191</a></p></li>"}]}, "summary": {"content": "<p>States report quarterly Medicaid expenditures on Form CMS-64 and quarterly Children's Health Insurance Program (CHIP) expenditures on Form CMS-21 to claim federal matching funds. In the T-MSIS Analytic Files (TAF), the CMS-64 category of service code data element on paid claim records should reflect the category where expenditures for the service are reported on Form CMS-64. Similarly, the CMS-21 category of service code on a paid claim record should reflect the category where expenditures for the service are reported on Form CMS-21. This analysis examines the extent to which records in the RX file are reported with a CMS-64 or CMS-21 category of service code value consistent with the beneficiary's enrollment in the Medicaid or CHIP program.</p>", "footnotes": []}, "originalIssueBriefId": "5221", "relatedTopics": [{"measureId": 111, "measureName": "Category of Service Code - IP", "groupId": 12, "groupName": "Financial Reporting", "order": 0}, {"measureId": 112, "measureName": "Category of Service Code - LT", "groupId": 12, "groupName": "Financial Reporting", "order": 1}, {"measureId": 113, "measureName": "Category of Service Code - OT", "groupId": 12, "groupName": "Financial Reporting", "order": 2}, {"measureId": 115, "measureName": "Federal Reimbursement Category Code - IP", "groupId": 12, "groupName": "Financial Reporting", "order": 4}, {"measureId": 116, "measureName": "Federal Reimbursement Category Code - LT", "groupId": 12, "groupName": "Financial Reporting", "order": 5}, {"measureId": 117, "measureName": "Federal Reimbursement Category Code - OT", "groupId": 12, "groupName": "Financial Reporting", "order": 6}, {"measureId": 118, "measureName": "Federal Reimbursement Category Code - RX", "groupId": 12, "groupName": "Financial Reporting", "order": 7}]}
115
{"measureId": 115, "measureName": "Federal Reimbursement Category Code - IP", "groupId": 12, "groupName": "Financial Reporting", "pdfVersionLink": "downloads/background-and-methods/TAF-DQ-Fed-Reimb-Cat-Cd-IP.pdf", "background": {"content": "<p class=\"msword-paragraph\"> <a id=\"_Hlk30592933\"></a> <a id=\"_Hlk95402275\"></a> Medicaid and the Children&rsquo;s Health Insurance Program (CHIP) are joint state-federal medical assistance programs in which the state administers the program and pays providers or health plans directly for covered services, and the federal government reimburses a set percentage of the state&rsquo;s expenditures (referred to as the \"federal match\"). Because the federal government applies different federal matching rates to Medicaid and CHIP beneficiaries, states report Medicaid and CHIP expenditure data separately.</p><p class=\"msword-paragraph\"> To claim federal matching funds for their medical assistance programs, states report aggregate expenditure data for Medicaid beneficiaries covered under Title XIX of the Social Security Act to the Centers for Medicare &amp; Medicaid Services (CMS) on Form CMS-64, <em> Quarterly Medicaid Statement of Expenditures. </em> States report aggregate expenditure data for the CHIP beneficiaries covered under Title XXI of the Social Security Act on Form CMS-21, <em> Quarterly CHIP Statement of Expenditures </em> . States may cover children using CHIP funds by expanding their Medicaid programs (called \"Medicaid expansion CHIP,\" or M-CHIP), creating a program separate from their existing Medicaid programs (called \"separate CHIP,\" or S-CHIP), or adopting a combination of both approaches. Expenditures for both M-CHIP and S-CHIP beneficiaries, which qualify for the higher CHIP federal match rate, are reported on Form CMS-21 and not Form CMS-64.</p><p class=\"msword-paragraph\"> There are three data elements in the T-MSIS Analytic Files (TAF) inpatient (IP), long-term care (LT), other services (OT), and pharmacy (RX) files that contain information about how states report Medicaid and CHIP expenditures to claim federal matching funds: the federal reimbursement category code, the CMS-64 category of service code, and the CMS-21 category of service code (Table 1). <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-2\" id=\"footnote-ref-2\">[1]</a> </sup> </sup> The federal reimbursement category code indicates whether the expenditure was reimbursed under Title XIX, Title XXI, the Affordable Care Act (ACA), or other legislation. As noted earlier, if the expenditure was covered by Title XIX of the Social Security Act, it should be reported on Form CMS-64; if the expenditure was covered by Title XXI of the Social Security Act it should be reported on Form CMS-21. The CMS-64 category of service code indicates the specific category of service on Form CMS-64 into which the state will report the Medicaid expenditures associated with a paid claim. The CMS-21 category of service code indicates the specific category of service on Form CMS-21 into which the state will report the CHIP expenditures associated with a paid claim.</p><p class=\"msword-table-title\"> Table 1. TAF variables that classify expenditures into federal reimbursement categories</p><table aria-label=\"Table 1. TAF variables that classify expenditures into federal reimbursement categories\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Variable </p> </th> <th> <p class=\"msword-table-header-center\"> TAF data element name </p> <p class=\"msword-table-header-center\"> (TAF RIF name in parentheses if different) </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> IP, LT, OT, and RX records expected to have non-missing values </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Description </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Federal reimbursement category code </p> </td> <td> <p class=\"msword-table-text-centered\"> CMS_64_FED_REIMBRSMT_CTGRY_CD </p> <p class=\"msword-table-text-centered\"> (CMS_64_FED_CTGRY_CD) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> All records </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> This code indicates whether the claim was matched with federal funding under Title XIX (value of &lsquo;01&rsquo;), Title XXI (&lsquo;02&rsquo;), the Affordable Care Act (&lsquo;03&rsquo;), <sup class=\"msword-superscript\"> a </sup> or federal funding under other legislation (&lsquo;04&rsquo;). </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> CMS-64 category of service code </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> XIX_SRVC_CTGRY_CD </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Only records representing expenditures that the state will report on the CMS-64, which should link to beneficiaries enrolled in non-CHIP Medicaid </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> A four-digit code (from 001A to 0050) indicating the line on the Form CMS-64 on which the state reported the expenditures associated with the claim. The Form CMS-64 is used to report expenditures that qualify for federal matching funds under Title XXI. A full list of the category of service and definition for each line can be found at <a aria-label=\"View Categories of service in the CMS-64 on Medicaid.gov\" href=\"https://www.medicaid.gov/medicaid/downloads/cms-649-base-category-of-services-definition-2-14.pdf\">https://www.medicaid.gov/medicaid/downloads/cms-649-base-category-of-services-definition-2-14.pdf</a> . </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> CMS-21 category of service code </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> XIX_SRVC_CTGRY_CD </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Only records representing expenditures that the state will report on the CMS-21, which should link to beneficiaries enrolled in Medicaid-expansion CHIP or Separate CHIP </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> A three-digit code (from 01A to 35B) indicating the category of service (or line) on the Form CMS-21 on which the state reported the expenditures associated with the claim. The Form CMS-21 is used to report expenditures that qualify for federal matching funds under Title XXI. A full list of the category of service and definition for each line can be found at <a aria-label=\"View MBES Category of Service Definitions for the CMS-21 Base Form\" href=\"https://www.medicaid.gov/medicaid/downloads/cms-21-base-category-of-services-definition-2-14.pdf\">https://www.medicaid.gov/medicaid/downloads/cms-21-base-category-of-services-definition-2-14.pdf</a> . </p> </td> </tr> </tbody></table><p class=\"msword-table-footnote\"> <sup class=\"msword-footnote-reference\"> a </sup> The federal reimbursement category code \"03\" was previously a valid value used by some states on claims for their ACA adult expansion population. However, <a id=\"_Hlk103946431\"></a> CMS retired the \"03\" value in September 2020 and states are expected to use the \"01\" value for this population moving forward since the enhanced match rate for these enrollees is authorized under Title XIX.</p><p class=\"msword-paragraph\"> If states are populating these data elements correctly, claim records that link to beneficiaries enrolled in Title XIX Medicaid will be coded to indicate the expenditure is reportable on Form CMS-64. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-3\" id=\"footnote-ref-3\">[2]</a> </sup> </sup> Similarly, claim records that link to beneficiaries enrolled in Title XXI CHIP&mdash;including both M-CHIP and S-CHIP programs&mdash;will be coded to indicate the expenditure is reportable on Form CMS-21.</p><p class=\"msword-paragraph\"> Other TAF data elements can be used to summarize Medicaid and CHIP spending associated with certain services or benefit categories, including the state-assigned type of service code, the federally-assigned service category code, and the benefit type code. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-4\" id=\"footnote-ref-4\">[3]</a> </sup> </sup> However, those data elements will not necessarily line up with the CMS-64 or CMS-21 categories that states use to report expenditures for the purposes of federal reimbursement.</p><p class=\"msword-paragraph\"> In this data quality assessment, we evaluate the percentage of records in each claims file reported with a federal reimbursement category code that is consistent with the beneficiary&rsquo;s enrollment in the Medicaid or CHIP programs. We also evaluate the percentage of records in each claims file reported with a CMS-64 or CMS-21 category of service code consistent with the beneficiary&rsquo;s enrollment in the Medicaid or CHIP program.</p><ol> <li class=\"footnoteBody\" id=\"footnote-2\" value=\"1\"> <p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page, and a crosswalk of variable names can be found in the guide &ldquo;Production of the TAF Research Identifiable Files.&rdquo; </p> <p> <a href=\"#footnote-ref-2\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-3\" value=\"2\"> <p class=\"msword-footnote-text\"> More information about differences between expenditures in the TAF and the CMS-64 data can be found in the DQ Atlas single topic displays under the Expenditure Benchmarking topic area. </p> <p> <a href=\"#footnote-ref-3\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-4\" value=\"3\"> <p class=\"msword-footnote-text\"> More information on states with missing or invalid type of service code can be found in the DQ Atlas single topic displays for <a aria-label=\"View DQ Atlas single topic display for Type of Service - IP\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m52\">Type of Service - IP</a> , <a aria-label=\"View DQ Atlas single topic display for Type of Service - OT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m53\">Type of Service - OT</a> , <a aria-label=\"View DQ Atlas single topic display for Type of Service - LT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m54\">Type of Service - LT</a> , and <a aria-label=\"View DQ Atlas single topic display for Type of Service - RX\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m55\">Type of Service - RX</a> . For more information about the FASC code, see the methodology brief, &ldquo;Assigning TAF Records to a Federally Assigned Service Category,&rdquo; on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page. </p> <p> <a href=\"#footnote-ref-4\">&uarr;</a> </p> </li></ol>", "footnotes": [{"number": 2, "content": "<li class=\"footnoteBody\" id=\"footnote-2\" value=\"1\"><p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page, and a crosswalk of variable names can be found in the guide \u201cProduction of the TAF Research Identifiable Files.\u201d </p><p><a href=\"#footnote-ref-2\">\u2191</a></p></li>"}, {"number": 3, "content": "<li class=\"footnoteBody\" id=\"footnote-3\" value=\"2\"><p class=\"msword-footnote-text\"> More information about differences between expenditures in the TAF and the CMS-64 data can be found in the DQ Atlas single topic displays under the Expenditure Benchmarking topic area. </p><p><a href=\"#footnote-ref-3\">\u2191</a></p></li>"}, {"number": 4, "content": "<li class=\"footnoteBody\" id=\"footnote-4\" value=\"3\"><p class=\"msword-footnote-text\"> More information on states with missing or invalid type of service code can be found in the DQ Atlas single topic displays for <a aria-label=\"View DQ Atlas single topic display for Type of Service - IP\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m52\">Type of Service - IP</a> , <a aria-label=\"View DQ Atlas single topic display for Type of Service - OT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m53\">Type of Service - OT</a> , <a aria-label=\"View DQ Atlas single topic display for Type of Service - LT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m54\">Type of Service - LT</a> , and <a aria-label=\"View DQ Atlas single topic display for Type of Service - RX\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m55\">Type of Service - RX</a> . For more information about the FASC code, see the methodology brief, \u201cAssigning TAF Records to a Federally Assigned Service Category,\u201d on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page. </p><p><a href=\"#footnote-ref-4\">\u2191</a></p></li>"}]}, "methods": {"content": "<p class=\"msword-paragraph\"> We began by selecting all records from the IP, LT, OT, and RX claims files that represented Medicaid and S-CHIP fee-for-service (FFS), capitation, and supplemental payments based on the claim type code. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-2\" id=\"footnote-ref-2\">[4]</a> </sup> </sup> <sup> , </sup> <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-3\" id=\"footnote-ref-3\">[5]</a> </sup> </sup> We excluded managed care encounter records from the analysis because the payments recorded on those claims do not represent state expenditures and are not recorded on the CMS-64 or CMS-21. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-4\" id=\"footnote-ref-4\">[6]</a> </sup> </sup> We also excluded service tracking claims from the analysis because these records are lump-sum payments that that cannot be linked to an eligibility record. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-5\" id=\"footnote-ref-5\">[7]</a> </sup> </sup></p><p class=\"msword-paragraph\"> To determine whether the beneficiary was enrolled in Medicaid, M-CHIP, or S-CHIP on the date of service, we linked the claims records to the matching eligibility record using the unique beneficiary identifier coded on the claim (MSIS ID). We determined Medicaid, M-CHIP, and S-CHIP enrollment by examining the CHIP code on records in the TAF Demographic and Eligibility (DE) file from the month that corresponded to the date of service on the claim. We excluded from the analysis claims records with a missing or invalid beneficiary identifier. Additionally, we excluded claims that did not link to an eligibility record, as well as those that linked to an eligibility record but did not have a CHIP code populated (indicating the individual was enrolled in Medicaid or CHIP) during the date of service on the claim. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-6\" id=\"footnote-ref-6\">[8]</a> </sup> </sup></p><p class=\"msword-paragraph\"> Finally, we calculated the percentage of records in each file with a federal reimbursement category code consistent with the beneficiary&rsquo;s reported enrollment in Medicaid, M-CHIP, or S-CHIP. The expected coding for federal reimbursement category code based on CHIP code is shown in Table 2. Because Medicaid beneficiaries enrolled in an adult expansion eligibility group may have a different federal reimbursement category code than Medicaid beneficiaries not enrolled in such a group, we examined these two groups of Medicaid beneficiaries separately. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-7\" id=\"footnote-ref-7\">[9]</a> </sup> </sup> We also calculated the percentage of records with a CMS-64 or CMS-21 category of service code consistent with the beneficiary&rsquo;s enrollment in the Medicaid or CHIP program. The expected coding for CMS-64 and CMS-21 category of service code based on CHIP code is shown in Table 3.</p><p class=\"msword-table-title\"> Table 2. Expected coding for federal reimbursement category code</p><table aria-label=\"Table 2. Expected coding for federal reimbursement category code\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Enrollment type </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> CHIP code on eligibility record (CHIP_CD) </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Latest eligibility group on eligibility record (ELGBLTY_GRP_CD_LTST) </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Expected federal reimbursement category code on claim record </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Medicaid &ndash; Adult expansion group </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 1 </strong> (Medicaid) </p> </td> <td> <p class=\"msword-table-text-centered\"> <strong> 72 </strong> (Adult Group - Individuals at or below 133% FPL Age 19 through 64 - newly eligible for all states) </p> <p class=\"msword-table-text-centered\"> <strong> 73 </strong> (Adult Group - Individuals at or below 133% FPL Age 19 through 64- not newly eligible for non 1905z(3) states), </p> <p class=\"msword-table-text-centered\"> <strong> 74 </strong> (Adult Group - Individuals at or below 133% FPL Age 19 through 64 &ndash; not newly eligible parent/ caretaker relative(s) in 1905z(3) states), or </p> <p class=\"msword-table-text-centered\"> <strong> 75 </strong> (Adult Group - Individuals at or below 133% FPL Age 19 through 64- not newly eligible non-parent/ caretaker-relative(s) in 1905z(3) states) </p> </td> <td> <p class=\"msword-table-text-centered\"> <strong> 01 </strong> (Federal funding under Title XIX) or </p> <p class=\"msword-table-text-centered\"> <strong> 03 </strong> (Federal funding under ACA) <sup class=\"msword-superscript\"> a </sup> </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Medicaid &ndash; All other </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 1 </strong> (Medicaid) </p> </td> <td> <p class=\"msword-table-text-centered\"> Any valid code or null/missing, except: </p> <p class=\"msword-table-text-centered\"> <strong> 72, 73, 74, 75, </strong> or </p> <p class=\"msword-table-text-centered\"> <strong> 61-68 </strong> (CHIP eligibility groups) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 01 </strong> (Federal funding under Title XIX) </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> M-CHIP </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 2 </strong> (M-CHIP) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> N/A </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 02 </strong> (Federal funding under Title XXI) </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> S-CHIP </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 3 </strong> (S-CHIP) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> N/A </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 02 </strong> (Federal funding under Title XXI) </p> </td> </tr> </tbody></table><p class=\"msword-table-footnote\"> <sup class=\"msword-footnote-reference\"> a </sup> In this assessment, we consider both \"01\" and \"03\" to be consistent values for Medicaid-enrolled beneficiaries in the adult expansion eligibility groups. The value \"03\" (Federal funding under ACA) was retired as a valid value on September 30, 2020 and while the value is still present in the data before that date, we would expect to see relatively few claims with this value after that date.</p><p class=\"msword-table-footnote\"> ACA = Affordable Care Act; FPL = Federal Poverty Level; N/A = not available.</p><p class=\"msword-table-title\"> Table 3. Expected coding for CMS-64 and CMS-21 category of service codes</p><table aria-label=\"Table 3. Expected coding for CMS-64 and CMS-21 category of service codes\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> CHIP code on eligibility record (CHIP_CD) </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Expected CMS-64 category of service code on claims record </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Expected CMS-21 category of service code on claims record </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> <strong> 1 </strong> (Medicaid) </p> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> Any valid value for CMS-64 category of service </li> </ul> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> Field should be blank </li> </ul> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> <strong> 2 </strong> (M-CHIP) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Field should be blank </p> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> Any valid value for CMS-21 category of service </li> </ul> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> <strong> 3 </strong> (S-CHIP) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Field should be blank </p> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> Any valid value for CMS-21 category of service </li> </ul> </td> </tr> </tbody></table><p class=\"msword-header\"> Data quality assessment criteria</p><p class=\"msword-paragraph\"> We categorized each state as having low, medium, or high data quality concern for the federal reimbursement category code, depending on the percentage of records with a federal reimbursement category code consistent with the beneficiary&rsquo;s enrollment in the Medicaid, M-CHIP, or S-CHIP programs, as shown in Table 4.</p><p class=\"msword-table-title\"> Table 4. Criteria for DQ assessment of federal reimbursement category code</p><table aria-label=\"Table 4. Criteria for DQ assessment of federal reimbursement category code\" class=\"dq-assessment-table\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Percentage of claim lines with a federal reimbursement category code consistent with program enrollment </p> </th> <th class=\"msword-table-header-center dq-assessment-col\"> <p class=\"msword-table-header-center\"> DQ assessment </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &ge; 90 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level low\"> <p class=\"msword-table-text-centered\"> Low concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 80 percent &le; x &lt; 90 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level medium\"> <p class=\"msword-table-text-centered\"> Medium concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 50 percent &le; x &lt; 80 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level high\"> <p class=\"msword-table-text-centered\"> High concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &lt; 50 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level unusable\"> <p class=\"msword-table-text-centered\"> Unusable </p> </td> </tr> </tbody></table><p class=\"msword-paragraph\"> We categorized each state as having low, medium, or high data quality concern for the category of service code, depending on the percentage of records with a CMS-64 or CMS-21 category of service code consistent with the beneficiary&rsquo;s enrollment in the Medicaid, M-CHIP, or S-CHIP programs, as shown in Table 5. As shown in Table 3, only the CMS-64 or CMS-21 category of service code is expected to be populated on a single claim record. When both fields were populated on the same claim (even if one or both values were invalid), that record was inconsistent with enrollment in the Medicaid, M-CHIP, or S-CHIP programs for the purposes of this analysis.</p><p class=\"msword-table-title\"> Table 5. Criteria for DQ assessment of category of service codes</p><table aria-label=\"Table 5. Criteria for DQ assessment of category of service codes\" class=\"dq-assessment-table\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Percentage of claim lines with a CMS-64 category of service code or a CMS-21 category of service code consistent with program enrollment </p> </th> <th class=\"msword-table-header-center dq-assessment-col\"> <p class=\"msword-table-header-center\"> DQ assessment </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &ge; 90 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level low\"> <p class=\"msword-table-text-centered\"> Low concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 80 percent &le; x &lt; 90 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level medium\"> <p class=\"msword-table-text-centered\"> Medium concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 50 percent &le; x &lt; 80 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level high\"> <p class=\"msword-table-text-centered\"> High concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &lt; 50 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level unusable\"> <p class=\"msword-table-text-centered\"> Unusable </p> </td> </tr> </tbody></table><ol> <li class=\"footnoteBody\" id=\"footnote-2\" value=\"4\"> <p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page, and a crosswalk of variable names can be found in the guide &ldquo;Production of the TAF Research Identifiable Files.&rdquo; </p> <p> <a href=\"#footnote-ref-2\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-3\" value=\"5\"> <p class=\"msword-footnote-text\"> FFS claims representing Medicaid or M-CHIP services have a claim type code (CLM_TYPE_CD) value of 1, capitation payments have a claim type code value of 2, and supplemental payments have a claim type code value of 5. FFS claims representing S-CHIP benefits have a claim type code value of A, capitation payments have a claim type code value of B, and supplemental payments have a claim type code value of E. </p> <p> <a href=\"#footnote-ref-3\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-4\" value=\"6\"> <p class=\"msword-footnote-text\"> Payment data on managed care encounter records are redacted from the TAF RIFs. </p> <p> <a href=\"#footnote-ref-4\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-5\" value=\"7\"> <p class=\"msword-footnote-text\"> Managed care encounter records representing Medicaid or M-CHIP services have a claim type code value of 3 and service tracking claims have a claim type code value of 4. Managed care encounter records representing S-CHIP benefits have a claim type code value of C, and service tracking claims have a claim type code value of D. </p> <p> <a href=\"#footnote-ref-5\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-6\" value=\"8\"> <p class=\"msword-footnote-text\"> Once an individual is determined eligible for Medicaid, coverage is effective either on the date of application or the first day of the month of application. Benefits also may be covered retroactively for up to three months prior to the month of application if the individual would have been eligible during that period had he or she applied. States are required to update beneficiaries&rsquo; eligibility records in T-MSIS to reflect the retroactive coverage period. However, if a state did not update the eligibility record of a beneficiary to reflect the retroactive coverage period, enrollment information like CHIP code may be missing during the date of service on a paid claim. </p> <p> <a href=\"#footnote-ref-6\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-7\" value=\"9\"> <p class=\"msword-footnote-text\"> We determined the eligibility group by using ELGBLTY_GRP_CD_LTST, the most recent eligibility group reported for the beneficiary in the calendar year. </p> <p> <a href=\"#footnote-ref-7\">&uarr;</a> </p> </li></ol>", "footnotes": [{"number": 2, "content": "<li class=\"footnoteBody\" id=\"footnote-2\" value=\"4\"><p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page, and a crosswalk of variable names can be found in the guide \u201cProduction of the TAF Research Identifiable Files.\u201d </p><p><a href=\"#footnote-ref-2\">\u2191</a></p></li>"}, {"number": 3, "content": "<li class=\"footnoteBody\" id=\"footnote-3\" value=\"5\"><p class=\"msword-footnote-text\"> FFS claims representing Medicaid or M-CHIP services have a claim type code (CLM_TYPE_CD) value of 1, capitation payments have a claim type code value of 2, and supplemental payments have a claim type code value of 5. FFS claims representing S-CHIP benefits have a claim type code value of A, capitation payments have a claim type code value of B, and supplemental payments have a claim type code value of E. </p><p><a href=\"#footnote-ref-3\">\u2191</a></p></li>"}, {"number": 4, "content": "<li class=\"footnoteBody\" id=\"footnote-4\" value=\"6\"><p class=\"msword-footnote-text\"> Payment data on managed care encounter records are redacted from the TAF RIFs. </p><p><a href=\"#footnote-ref-4\">\u2191</a></p></li>"}, {"number": 5, "content": "<li class=\"footnoteBody\" id=\"footnote-5\" value=\"7\"><p class=\"msword-footnote-text\"> Managed care encounter records representing Medicaid or M-CHIP services have a claim type code value of 3 and service tracking claims have a claim type code value of 4. Managed care encounter records representing S-CHIP benefits have a claim type code value of C, and service tracking claims have a claim type code value of D. </p><p><a href=\"#footnote-ref-5\">\u2191</a></p></li>"}, {"number": 6, "content": "<li class=\"footnoteBody\" id=\"footnote-6\" value=\"8\"><p class=\"msword-footnote-text\"> Once an individual is determined eligible for Medicaid, coverage is effective either on the date of application or the first day of the month of application. Benefits also may be covered retroactively for up to three months prior to the month of application if the individual would have been eligible during that period had he or she applied. States are required to update beneficiaries\u2019 eligibility records in T-MSIS to reflect the retroactive coverage period. However, if a state did not update the eligibility record of a beneficiary to reflect the retroactive coverage period, enrollment information like CHIP code may be missing during the date of service on a paid claim. </p><p><a href=\"#footnote-ref-6\">\u2191</a></p></li>"}, {"number": 7, "content": "<li class=\"footnoteBody\" id=\"footnote-7\" value=\"9\"><p class=\"msword-footnote-text\"> We determined the eligibility group by using ELGBLTY_GRP_CD_LTST, the most recent eligibility group reported for the beneficiary in the calendar year. </p><p><a href=\"#footnote-ref-7\">\u2191</a></p></li>"}]}, "summary": {"content": "<p>The federal reimbursement category code indicates whether a claim represents state expenditures that qualify for federal matching funds under Title XIX (Medicaid), Title XXI (CHIP), or other legislation. This analysis examines the extent to which records in the IP file are reported with a federal reimbursement category code consistent with the beneficiary's enrollment in the Medicaid or CHIP program.</p>", "footnotes": []}, "originalIssueBriefId": "5221", "relatedTopics": [{"measureId": 111, "measureName": "Category of Service Code - IP", "groupId": 12, "groupName": "Financial Reporting", "order": 0}, {"measureId": 112, "measureName": "Category of Service Code - LT", "groupId": 12, "groupName": "Financial Reporting", "order": 1}, {"measureId": 113, "measureName": "Category of Service Code - OT", "groupId": 12, "groupName": "Financial Reporting", "order": 2}, {"measureId": 114, "measureName": "Category of Service Code - RX", "groupId": 12, "groupName": "Financial Reporting", "order": 3}, {"measureId": 116, "measureName": "Federal Reimbursement Category Code - LT", "groupId": 12, "groupName": "Financial Reporting", "order": 5}, {"measureId": 117, "measureName": "Federal Reimbursement Category Code - OT", "groupId": 12, "groupName": "Financial Reporting", "order": 6}, {"measureId": 118, "measureName": "Federal Reimbursement Category Code - RX", "groupId": 12, "groupName": "Financial Reporting", "order": 7}]}
116
{"measureId": 116, "measureName": "Federal Reimbursement Category Code - LT", "groupId": 12, "groupName": "Financial Reporting", "pdfVersionLink": "downloads/background-and-methods/TAF-DQ-Fed-Reimb-Cat-Cd-LT.pdf", "background": {"content": "<p class=\"msword-paragraph\"> <a id=\"_Hlk30592933\"></a> <a id=\"_Hlk95402275\"></a> Medicaid and the Children&rsquo;s Health Insurance Program (CHIP) are joint state-federal medical assistance programs in which the state administers the program and pays providers or health plans directly for covered services, and the federal government reimburses a set percentage of the state&rsquo;s expenditures (referred to as the \"federal match\"). Because the federal government applies different federal matching rates to Medicaid and CHIP beneficiaries, states report Medicaid and CHIP expenditure data separately.</p><p class=\"msword-paragraph\"> To claim federal matching funds for their medical assistance programs, states report aggregate expenditure data for Medicaid beneficiaries covered under Title XIX of the Social Security Act to the Centers for Medicare &amp; Medicaid Services (CMS) on Form CMS-64, <em> Quarterly Medicaid Statement of Expenditures. </em> States report aggregate expenditure data for the CHIP beneficiaries covered under Title XXI of the Social Security Act on Form CMS-21, <em> Quarterly CHIP Statement of Expenditures </em> . States may cover children using CHIP funds by expanding their Medicaid programs (called \"Medicaid expansion CHIP,\" or M-CHIP), creating a program separate from their existing Medicaid programs (called \"separate CHIP,\" or S-CHIP), or adopting a combination of both approaches. Expenditures for both M-CHIP and S-CHIP beneficiaries, which qualify for the higher CHIP federal match rate, are reported on Form CMS-21 and not Form CMS-64.</p><p class=\"msword-paragraph\"> There are three data elements in the T-MSIS Analytic Files (TAF) inpatient (IP), long-term care (LT), other services (OT), and pharmacy (RX) files that contain information about how states report Medicaid and CHIP expenditures to claim federal matching funds: the federal reimbursement category code, the CMS-64 category of service code, and the CMS-21 category of service code (Table 1). <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-2\" id=\"footnote-ref-2\">[1]</a> </sup> </sup> The federal reimbursement category code indicates whether the expenditure was reimbursed under Title XIX, Title XXI, the Affordable Care Act (ACA), or other legislation. As noted earlier, if the expenditure was covered by Title XIX of the Social Security Act, it should be reported on Form CMS-64; if the expenditure was covered by Title XXI of the Social Security Act it should be reported on Form CMS-21. The CMS-64 category of service code indicates the specific category of service on Form CMS-64 into which the state will report the Medicaid expenditures associated with a paid claim. The CMS-21 category of service code indicates the specific category of service on Form CMS-21 into which the state will report the CHIP expenditures associated with a paid claim.</p><p class=\"msword-table-title\"> Table 1. TAF variables that classify expenditures into federal reimbursement categories</p><table aria-label=\"Table 1. TAF variables that classify expenditures into federal reimbursement categories\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Variable </p> </th> <th> <p class=\"msword-table-header-center\"> TAF data element name </p> <p class=\"msword-table-header-center\"> (TAF RIF name in parentheses if different) </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> IP, LT, OT, and RX records expected to have non-missing values </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Description </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Federal reimbursement category code </p> </td> <td> <p class=\"msword-table-text-centered\"> CMS_64_FED_REIMBRSMT_CTGRY_CD </p> <p class=\"msword-table-text-centered\"> (CMS_64_FED_CTGRY_CD) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> All records </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> This code indicates whether the claim was matched with federal funding under Title XIX (value of &lsquo;01&rsquo;), Title XXI (&lsquo;02&rsquo;), the Affordable Care Act (&lsquo;03&rsquo;), <sup class=\"msword-superscript\"> a </sup> or federal funding under other legislation (&lsquo;04&rsquo;). </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> CMS-64 category of service code </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> XIX_SRVC_CTGRY_CD </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Only records representing expenditures that the state will report on the CMS-64, which should link to beneficiaries enrolled in non-CHIP Medicaid </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> A four-digit code (from 001A to 0050) indicating the line on the Form CMS-64 on which the state reported the expenditures associated with the claim. The Form CMS-64 is used to report expenditures that qualify for federal matching funds under Title XXI. A full list of the category of service and definition for each line can be found at <a aria-label=\"View Categories of service in the CMS-64 on Medicaid.gov\" href=\"https://www.medicaid.gov/medicaid/downloads/cms-649-base-category-of-services-definition-2-14.pdf\">https://www.medicaid.gov/medicaid/downloads/cms-649-base-category-of-services-definition-2-14.pdf</a> . </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> CMS-21 category of service code </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> XIX_SRVC_CTGRY_CD </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Only records representing expenditures that the state will report on the CMS-21, which should link to beneficiaries enrolled in Medicaid-expansion CHIP or Separate CHIP </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> A three-digit code (from 01A to 35B) indicating the category of service (or line) on the Form CMS-21 on which the state reported the expenditures associated with the claim. The Form CMS-21 is used to report expenditures that qualify for federal matching funds under Title XXI. A full list of the category of service and definition for each line can be found at <a aria-label=\"View MBES Category of Service Definitions for the CMS-21 Base Form\" href=\"https://www.medicaid.gov/medicaid/downloads/cms-21-base-category-of-services-definition-2-14.pdf\">https://www.medicaid.gov/medicaid/downloads/cms-21-base-category-of-services-definition-2-14.pdf</a> . </p> </td> </tr> </tbody></table><p class=\"msword-table-footnote\"> <sup class=\"msword-footnote-reference\"> a </sup> The federal reimbursement category code \"03\" was previously a valid value used by some states on claims for their ACA adult expansion population. However, <a id=\"_Hlk103946431\"></a> CMS retired the \"03\" value in September 2020 and states are expected to use the \"01\" value for this population moving forward since the enhanced match rate for these enrollees is authorized under Title XIX.</p><p class=\"msword-paragraph\"> If states are populating these data elements correctly, claim records that link to beneficiaries enrolled in Title XIX Medicaid will be coded to indicate the expenditure is reportable on Form CMS-64. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-3\" id=\"footnote-ref-3\">[2]</a> </sup> </sup> Similarly, claim records that link to beneficiaries enrolled in Title XXI CHIP&mdash;including both M-CHIP and S-CHIP programs&mdash;will be coded to indicate the expenditure is reportable on Form CMS-21.</p><p class=\"msword-paragraph\"> Other TAF data elements can be used to summarize Medicaid and CHIP spending associated with certain services or benefit categories, including the state-assigned type of service code, the federally-assigned service category code, and the benefit type code. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-4\" id=\"footnote-ref-4\">[3]</a> </sup> </sup> However, those data elements will not necessarily line up with the CMS-64 or CMS-21 categories that states use to report expenditures for the purposes of federal reimbursement.</p><p class=\"msword-paragraph\"> In this data quality assessment, we evaluate the percentage of records in each claims file reported with a federal reimbursement category code that is consistent with the beneficiary&rsquo;s enrollment in the Medicaid or CHIP programs. We also evaluate the percentage of records in each claims file reported with a CMS-64 or CMS-21 category of service code consistent with the beneficiary&rsquo;s enrollment in the Medicaid or CHIP program.</p><ol> <li class=\"footnoteBody\" id=\"footnote-2\" value=\"1\"> <p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page, and a crosswalk of variable names can be found in the guide &ldquo;Production of the TAF Research Identifiable Files.&rdquo; </p> <p> <a href=\"#footnote-ref-2\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-3\" value=\"2\"> <p class=\"msword-footnote-text\"> More information about differences between expenditures in the TAF and the CMS-64 data can be found in the DQ Atlas single topic displays under the Expenditure Benchmarking topic area. </p> <p> <a href=\"#footnote-ref-3\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-4\" value=\"3\"> <p class=\"msword-footnote-text\"> More information on states with missing or invalid type of service code can be found in the DQ Atlas single topic displays for <a aria-label=\"View DQ Atlas single topic display for Type of Service - IP\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m52\">Type of Service - IP</a> , <a aria-label=\"View DQ Atlas single topic display for Type of Service - OT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m53\">Type of Service - OT</a> , <a aria-label=\"View DQ Atlas single topic display for Type of Service - LT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m54\">Type of Service - LT</a> , and <a aria-label=\"View DQ Atlas single topic display for Type of Service - RX\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m55\">Type of Service - RX</a> . For more information about the FASC code, see the methodology brief, &ldquo;Assigning TAF Records to a Federally Assigned Service Category,&rdquo; on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page. </p> <p> <a href=\"#footnote-ref-4\">&uarr;</a> </p> </li></ol>", "footnotes": [{"number": 2, "content": "<li class=\"footnoteBody\" id=\"footnote-2\" value=\"1\"><p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page, and a crosswalk of variable names can be found in the guide \u201cProduction of the TAF Research Identifiable Files.\u201d </p><p><a href=\"#footnote-ref-2\">\u2191</a></p></li>"}, {"number": 3, "content": "<li class=\"footnoteBody\" id=\"footnote-3\" value=\"2\"><p class=\"msword-footnote-text\"> More information about differences between expenditures in the TAF and the CMS-64 data can be found in the DQ Atlas single topic displays under the Expenditure Benchmarking topic area. </p><p><a href=\"#footnote-ref-3\">\u2191</a></p></li>"}, {"number": 4, "content": "<li class=\"footnoteBody\" id=\"footnote-4\" value=\"3\"><p class=\"msword-footnote-text\"> More information on states with missing or invalid type of service code can be found in the DQ Atlas single topic displays for <a aria-label=\"View DQ Atlas single topic display for Type of Service - IP\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m52\">Type of Service - IP</a> , <a aria-label=\"View DQ Atlas single topic display for Type of Service - OT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m53\">Type of Service - OT</a> , <a aria-label=\"View DQ Atlas single topic display for Type of Service - LT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m54\">Type of Service - LT</a> , and <a aria-label=\"View DQ Atlas single topic display for Type of Service - RX\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m55\">Type of Service - RX</a> . For more information about the FASC code, see the methodology brief, \u201cAssigning TAF Records to a Federally Assigned Service Category,\u201d on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page. </p><p><a href=\"#footnote-ref-4\">\u2191</a></p></li>"}]}, "methods": {"content": "<p class=\"msword-paragraph\"> We began by selecting all records from the IP, LT, OT, and RX claims files that represented Medicaid and S-CHIP fee-for-service (FFS), capitation, and supplemental payments based on the claim type code. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-2\" id=\"footnote-ref-2\">[4]</a> </sup> </sup> <sup> , </sup> <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-3\" id=\"footnote-ref-3\">[5]</a> </sup> </sup> We excluded managed care encounter records from the analysis because the payments recorded on those claims do not represent state expenditures and are not recorded on the CMS-64 or CMS-21. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-4\" id=\"footnote-ref-4\">[6]</a> </sup> </sup> We also excluded service tracking claims from the analysis because these records are lump-sum payments that that cannot be linked to an eligibility record. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-5\" id=\"footnote-ref-5\">[7]</a> </sup> </sup></p><p class=\"msword-paragraph\"> To determine whether the beneficiary was enrolled in Medicaid, M-CHIP, or S-CHIP on the date of service, we linked the claims records to the matching eligibility record using the unique beneficiary identifier coded on the claim (MSIS ID). We determined Medicaid, M-CHIP, and S-CHIP enrollment by examining the CHIP code on records in the TAF Demographic and Eligibility (DE) file from the month that corresponded to the date of service on the claim. We excluded from the analysis claims records with a missing or invalid beneficiary identifier. Additionally, we excluded claims that did not link to an eligibility record, as well as those that linked to an eligibility record but did not have a CHIP code populated (indicating the individual was enrolled in Medicaid or CHIP) during the date of service on the claim. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-6\" id=\"footnote-ref-6\">[8]</a> </sup> </sup></p><p class=\"msword-paragraph\"> Finally, we calculated the percentage of records in each file with a federal reimbursement category code consistent with the beneficiary&rsquo;s reported enrollment in Medicaid, M-CHIP, or S-CHIP. The expected coding for federal reimbursement category code based on CHIP code is shown in Table 2. Because Medicaid beneficiaries enrolled in an adult expansion eligibility group may have a different federal reimbursement category code than Medicaid beneficiaries not enrolled in such a group, we examined these two groups of Medicaid beneficiaries separately. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-7\" id=\"footnote-ref-7\">[9]</a> </sup> </sup> We also calculated the percentage of records with a CMS-64 or CMS-21 category of service code consistent with the beneficiary&rsquo;s enrollment in the Medicaid or CHIP program. The expected coding for CMS-64 and CMS-21 category of service code based on CHIP code is shown in Table 3.</p><p class=\"msword-table-title\"> Table 2. Expected coding for federal reimbursement category code</p><table aria-label=\"Table 2. Expected coding for federal reimbursement category code\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Enrollment type </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> CHIP code on eligibility record (CHIP_CD) </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Latest eligibility group on eligibility record (ELGBLTY_GRP_CD_LTST) </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Expected federal reimbursement category code on claim record </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Medicaid &ndash; Adult expansion group </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 1 </strong> (Medicaid) </p> </td> <td> <p class=\"msword-table-text-centered\"> <strong> 72 </strong> (Adult Group - Individuals at or below 133% FPL Age 19 through 64 - newly eligible for all states) </p> <p class=\"msword-table-text-centered\"> <strong> 73 </strong> (Adult Group - Individuals at or below 133% FPL Age 19 through 64- not newly eligible for non 1905z(3) states), </p> <p class=\"msword-table-text-centered\"> <strong> 74 </strong> (Adult Group - Individuals at or below 133% FPL Age 19 through 64 &ndash; not newly eligible parent/ caretaker relative(s) in 1905z(3) states), or </p> <p class=\"msword-table-text-centered\"> <strong> 75 </strong> (Adult Group - Individuals at or below 133% FPL Age 19 through 64- not newly eligible non-parent/ caretaker-relative(s) in 1905z(3) states) </p> </td> <td> <p class=\"msword-table-text-centered\"> <strong> 01 </strong> (Federal funding under Title XIX) or </p> <p class=\"msword-table-text-centered\"> <strong> 03 </strong> (Federal funding under ACA) <sup class=\"msword-superscript\"> a </sup> </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Medicaid &ndash; All other </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 1 </strong> (Medicaid) </p> </td> <td> <p class=\"msword-table-text-centered\"> Any valid code or null/missing, except: </p> <p class=\"msword-table-text-centered\"> <strong> 72, 73, 74, 75, </strong> or </p> <p class=\"msword-table-text-centered\"> <strong> 61-68 </strong> (CHIP eligibility groups) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 01 </strong> (Federal funding under Title XIX) </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> M-CHIP </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 2 </strong> (M-CHIP) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> N/A </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 02 </strong> (Federal funding under Title XXI) </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> S-CHIP </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 3 </strong> (S-CHIP) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> N/A </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 02 </strong> (Federal funding under Title XXI) </p> </td> </tr> </tbody></table><p class=\"msword-table-footnote\"> <sup class=\"msword-footnote-reference\"> a </sup> In this assessment, we consider both \"01\" and \"03\" to be consistent values for Medicaid-enrolled beneficiaries in the adult expansion eligibility groups. The value \"03\" (Federal funding under ACA) was retired as a valid value on September 30, 2020 and while the value is still present in the data before that date, we would expect to see relatively few claims with this value after that date.</p><p class=\"msword-table-footnote\"> ACA = Affordable Care Act; FPL = Federal Poverty Level; N/A = not available.</p><p class=\"msword-table-title\"> Table 3. Expected coding for CMS-64 and CMS-21 category of service codes</p><table aria-label=\"Table 3. Expected coding for CMS-64 and CMS-21 category of service codes\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> CHIP code on eligibility record (CHIP_CD) </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Expected CMS-64 category of service code on claims record </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Expected CMS-21 category of service code on claims record </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> <strong> 1 </strong> (Medicaid) </p> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> Any valid value for CMS-64 category of service </li> </ul> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> Field should be blank </li> </ul> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> <strong> 2 </strong> (M-CHIP) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Field should be blank </p> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> Any valid value for CMS-21 category of service </li> </ul> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> <strong> 3 </strong> (S-CHIP) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Field should be blank </p> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> Any valid value for CMS-21 category of service </li> </ul> </td> </tr> </tbody></table><p class=\"msword-header\"> Data quality assessment criteria</p><p class=\"msword-paragraph\"> We categorized each state as having low, medium, or high data quality concern for the federal reimbursement category code, depending on the percentage of records with a federal reimbursement category code consistent with the beneficiary&rsquo;s enrollment in the Medicaid, M-CHIP, or S-CHIP programs, as shown in Table 4.</p><p class=\"msword-table-title\"> Table 4. Criteria for DQ assessment of federal reimbursement category code</p><table aria-label=\"Table 4. Criteria for DQ assessment of federal reimbursement category code\" class=\"dq-assessment-table\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Percentage of claim lines with a federal reimbursement category code consistent with program enrollment </p> </th> <th class=\"msword-table-header-center dq-assessment-col\"> <p class=\"msword-table-header-center\"> DQ assessment </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &ge; 90 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level low\"> <p class=\"msword-table-text-centered\"> Low concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 80 percent &le; x &lt; 90 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level medium\"> <p class=\"msword-table-text-centered\"> Medium concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 50 percent &le; x &lt; 80 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level high\"> <p class=\"msword-table-text-centered\"> High concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &lt; 50 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level unusable\"> <p class=\"msword-table-text-centered\"> Unusable </p> </td> </tr> </tbody></table><p class=\"msword-paragraph\"> We categorized each state as having low, medium, or high data quality concern for the category of service code, depending on the percentage of records with a CMS-64 or CMS-21 category of service code consistent with the beneficiary&rsquo;s enrollment in the Medicaid, M-CHIP, or S-CHIP programs, as shown in Table 5. As shown in Table 3, only the CMS-64 or CMS-21 category of service code is expected to be populated on a single claim record. When both fields were populated on the same claim (even if one or both values were invalid), that record was inconsistent with enrollment in the Medicaid, M-CHIP, or S-CHIP programs for the purposes of this analysis.</p><p class=\"msword-table-title\"> Table 5. Criteria for DQ assessment of category of service codes</p><table aria-label=\"Table 5. Criteria for DQ assessment of category of service codes\" class=\"dq-assessment-table\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Percentage of claim lines with a CMS-64 category of service code or a CMS-21 category of service code consistent with program enrollment </p> </th> <th class=\"msword-table-header-center dq-assessment-col\"> <p class=\"msword-table-header-center\"> DQ assessment </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &ge; 90 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level low\"> <p class=\"msword-table-text-centered\"> Low concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 80 percent &le; x &lt; 90 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level medium\"> <p class=\"msword-table-text-centered\"> Medium concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 50 percent &le; x &lt; 80 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level high\"> <p class=\"msword-table-text-centered\"> High concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &lt; 50 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level unusable\"> <p class=\"msword-table-text-centered\"> Unusable </p> </td> </tr> </tbody></table><ol> <li class=\"footnoteBody\" id=\"footnote-2\" value=\"4\"> <p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page, and a crosswalk of variable names can be found in the guide &ldquo;Production of the TAF Research Identifiable Files.&rdquo; </p> <p> <a href=\"#footnote-ref-2\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-3\" value=\"5\"> <p class=\"msword-footnote-text\"> FFS claims representing Medicaid or M-CHIP services have a claim type code (CLM_TYPE_CD) value of 1, capitation payments have a claim type code value of 2, and supplemental payments have a claim type code value of 5. FFS claims representing S-CHIP benefits have a claim type code value of A, capitation payments have a claim type code value of B, and supplemental payments have a claim type code value of E. </p> <p> <a href=\"#footnote-ref-3\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-4\" value=\"6\"> <p class=\"msword-footnote-text\"> Payment data on managed care encounter records are redacted from the TAF RIFs. </p> <p> <a href=\"#footnote-ref-4\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-5\" value=\"7\"> <p class=\"msword-footnote-text\"> Managed care encounter records representing Medicaid or M-CHIP services have a claim type code value of 3 and service tracking claims have a claim type code value of 4. Managed care encounter records representing S-CHIP benefits have a claim type code value of C, and service tracking claims have a claim type code value of D. </p> <p> <a href=\"#footnote-ref-5\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-6\" value=\"8\"> <p class=\"msword-footnote-text\"> Once an individual is determined eligible for Medicaid, coverage is effective either on the date of application or the first day of the month of application. Benefits also may be covered retroactively for up to three months prior to the month of application if the individual would have been eligible during that period had he or she applied. States are required to update beneficiaries&rsquo; eligibility records in T-MSIS to reflect the retroactive coverage period. However, if a state did not update the eligibility record of a beneficiary to reflect the retroactive coverage period, enrollment information like CHIP code may be missing during the date of service on a paid claim. </p> <p> <a href=\"#footnote-ref-6\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-7\" value=\"9\"> <p class=\"msword-footnote-text\"> We determined the eligibility group by using ELGBLTY_GRP_CD_LTST, the most recent eligibility group reported for the beneficiary in the calendar year. </p> <p> <a href=\"#footnote-ref-7\">&uarr;</a> </p> </li></ol>", "footnotes": [{"number": 2, "content": "<li class=\"footnoteBody\" id=\"footnote-2\" value=\"4\"><p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page, and a crosswalk of variable names can be found in the guide \u201cProduction of the TAF Research Identifiable Files.\u201d </p><p><a href=\"#footnote-ref-2\">\u2191</a></p></li>"}, {"number": 3, "content": "<li class=\"footnoteBody\" id=\"footnote-3\" value=\"5\"><p class=\"msword-footnote-text\"> FFS claims representing Medicaid or M-CHIP services have a claim type code (CLM_TYPE_CD) value of 1, capitation payments have a claim type code value of 2, and supplemental payments have a claim type code value of 5. FFS claims representing S-CHIP benefits have a claim type code value of A, capitation payments have a claim type code value of B, and supplemental payments have a claim type code value of E. </p><p><a href=\"#footnote-ref-3\">\u2191</a></p></li>"}, {"number": 4, "content": "<li class=\"footnoteBody\" id=\"footnote-4\" value=\"6\"><p class=\"msword-footnote-text\"> Payment data on managed care encounter records are redacted from the TAF RIFs. </p><p><a href=\"#footnote-ref-4\">\u2191</a></p></li>"}, {"number": 5, "content": "<li class=\"footnoteBody\" id=\"footnote-5\" value=\"7\"><p class=\"msword-footnote-text\"> Managed care encounter records representing Medicaid or M-CHIP services have a claim type code value of 3 and service tracking claims have a claim type code value of 4. Managed care encounter records representing S-CHIP benefits have a claim type code value of C, and service tracking claims have a claim type code value of D. </p><p><a href=\"#footnote-ref-5\">\u2191</a></p></li>"}, {"number": 6, "content": "<li class=\"footnoteBody\" id=\"footnote-6\" value=\"8\"><p class=\"msword-footnote-text\"> Once an individual is determined eligible for Medicaid, coverage is effective either on the date of application or the first day of the month of application. Benefits also may be covered retroactively for up to three months prior to the month of application if the individual would have been eligible during that period had he or she applied. States are required to update beneficiaries\u2019 eligibility records in T-MSIS to reflect the retroactive coverage period. However, if a state did not update the eligibility record of a beneficiary to reflect the retroactive coverage period, enrollment information like CHIP code may be missing during the date of service on a paid claim. </p><p><a href=\"#footnote-ref-6\">\u2191</a></p></li>"}, {"number": 7, "content": "<li class=\"footnoteBody\" id=\"footnote-7\" value=\"9\"><p class=\"msword-footnote-text\"> We determined the eligibility group by using ELGBLTY_GRP_CD_LTST, the most recent eligibility group reported for the beneficiary in the calendar year. </p><p><a href=\"#footnote-ref-7\">\u2191</a></p></li>"}]}, "summary": {"content": "<p>The federal reimbursement category code indicates whether a claim represents state expenditures that qualify for federal matching funds under Title XIX (Medicaid), Title XXI (CHIP), or other legislation. This analysis examines the extent to which records in the LT file are reported with a federal reimbursement category code consistent with the beneficiary's enrollment in the Medicaid or CHIP program.</p>", "footnotes": []}, "originalIssueBriefId": "5221", "relatedTopics": [{"measureId": 111, "measureName": "Category of Service Code - IP", "groupId": 12, "groupName": "Financial Reporting", "order": 0}, {"measureId": 112, "measureName": "Category of Service Code - LT", "groupId": 12, "groupName": "Financial Reporting", "order": 1}, {"measureId": 113, "measureName": "Category of Service Code - OT", "groupId": 12, "groupName": "Financial Reporting", "order": 2}, {"measureId": 114, "measureName": "Category of Service Code - RX", "groupId": 12, "groupName": "Financial Reporting", "order": 3}, {"measureId": 115, "measureName": "Federal Reimbursement Category Code - IP", "groupId": 12, "groupName": "Financial Reporting", "order": 4}, {"measureId": 117, "measureName": "Federal Reimbursement Category Code - OT", "groupId": 12, "groupName": "Financial Reporting", "order": 6}, {"measureId": 118, "measureName": "Federal Reimbursement Category Code - RX", "groupId": 12, "groupName": "Financial Reporting", "order": 7}]}
117
{"measureId": 117, "measureName": "Federal Reimbursement Category Code - OT", "groupId": 12, "groupName": "Financial Reporting", "pdfVersionLink": "downloads/background-and-methods/TAF-DQ-Fed-Srvc-Reimb-Cd-OT.pdf", "background": {"content": "<p class=\"msword-paragraph\"> <a id=\"_Hlk30592933\"></a> <a id=\"_Hlk95402275\"></a> Medicaid and the Children&rsquo;s Health Insurance Program (CHIP) are joint state-federal medical assistance programs in which the state administers the program and pays providers or health plans directly for covered services, and the federal government reimburses a set percentage of the state&rsquo;s expenditures (referred to as the \"federal match\"). Because the federal government applies different federal matching rates to Medicaid and CHIP beneficiaries, states report Medicaid and CHIP expenditure data separately.</p><p class=\"msword-paragraph\"> To claim federal matching funds for their medical assistance programs, states report aggregate expenditure data for Medicaid beneficiaries covered under Title XIX of the Social Security Act to the Centers for Medicare &amp; Medicaid Services (CMS) on Form CMS-64, <em> Quarterly Medicaid Statement of Expenditures. </em> States report aggregate expenditure data for the CHIP beneficiaries covered under Title XXI of the Social Security Act on Form CMS-21, <em> Quarterly CHIP Statement of Expenditures </em> . States may cover children using CHIP funds by expanding their Medicaid programs (called \"Medicaid expansion CHIP,\" or M-CHIP), creating a program separate from their existing Medicaid programs (called \"separate CHIP,\" or S-CHIP), or adopting a combination of both approaches. Expenditures for both M-CHIP and S-CHIP beneficiaries, which qualify for the higher CHIP federal match rate, are reported on Form CMS-21 and not Form CMS-64.</p><p class=\"msword-paragraph\"> There are three data elements in the T-MSIS Analytic Files (TAF) inpatient (IP), long-term care (LT), other services (OT), and pharmacy (RX) files that contain information about how states report Medicaid and CHIP expenditures to claim federal matching funds: the federal reimbursement category code, the CMS-64 category of service code, and the CMS-21 category of service code (Table 1). <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-2\" id=\"footnote-ref-2\">[1]</a> </sup> </sup> The federal reimbursement category code indicates whether the expenditure was reimbursed under Title XIX, Title XXI, the Affordable Care Act (ACA), or other legislation. As noted earlier, if the expenditure was covered by Title XIX of the Social Security Act, it should be reported on Form CMS-64; if the expenditure was covered by Title XXI of the Social Security Act it should be reported on Form CMS-21. The CMS-64 category of service code indicates the specific category of service on Form CMS-64 into which the state will report the Medicaid expenditures associated with a paid claim. The CMS-21 category of service code indicates the specific category of service on Form CMS-21 into which the state will report the CHIP expenditures associated with a paid claim.</p><p class=\"msword-table-title\"> Table 1. TAF variables that classify expenditures into federal reimbursement categories</p><table aria-label=\"Table 1. TAF variables that classify expenditures into federal reimbursement categories\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Variable </p> </th> <th> <p class=\"msword-table-header-center\"> TAF data element name </p> <p class=\"msword-table-header-center\"> (TAF RIF name in parentheses if different) </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> IP, LT, OT, and RX records expected to have non-missing values </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Description </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Federal reimbursement category code </p> </td> <td> <p class=\"msword-table-text-centered\"> CMS_64_FED_REIMBRSMT_CTGRY_CD </p> <p class=\"msword-table-text-centered\"> (CMS_64_FED_CTGRY_CD) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> All records </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> This code indicates whether the claim was matched with federal funding under Title XIX (value of &lsquo;01&rsquo;), Title XXI (&lsquo;02&rsquo;), the Affordable Care Act (&lsquo;03&rsquo;), <sup class=\"msword-superscript\"> a </sup> or federal funding under other legislation (&lsquo;04&rsquo;). </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> CMS-64 category of service code </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> XIX_SRVC_CTGRY_CD </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Only records representing expenditures that the state will report on the CMS-64, which should link to beneficiaries enrolled in non-CHIP Medicaid </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> A four-digit code (from 001A to 0050) indicating the line on the Form CMS-64 on which the state reported the expenditures associated with the claim. The Form CMS-64 is used to report expenditures that qualify for federal matching funds under Title XXI. A full list of the category of service and definition for each line can be found at <a aria-label=\"View Categories of service in the CMS-64 on Medicaid.gov\" href=\"https://www.medicaid.gov/medicaid/downloads/cms-649-base-category-of-services-definition-2-14.pdf\">https://www.medicaid.gov/medicaid/downloads/cms-649-base-category-of-services-definition-2-14.pdf</a> . </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> CMS-21 category of service code </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> XIX_SRVC_CTGRY_CD </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Only records representing expenditures that the state will report on the CMS-21, which should link to beneficiaries enrolled in Medicaid-expansion CHIP or Separate CHIP </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> A three-digit code (from 01A to 35B) indicating the category of service (or line) on the Form CMS-21 on which the state reported the expenditures associated with the claim. The Form CMS-21 is used to report expenditures that qualify for federal matching funds under Title XXI. A full list of the category of service and definition for each line can be found at <a aria-label=\"View MBES Category of Service Definitions for the CMS-21 Base Form\" href=\"https://www.medicaid.gov/medicaid/downloads/cms-21-base-category-of-services-definition-2-14.pdf\">https://www.medicaid.gov/medicaid/downloads/cms-21-base-category-of-services-definition-2-14.pdf</a> . </p> </td> </tr> </tbody></table><p class=\"msword-table-footnote\"> <sup class=\"msword-footnote-reference\"> a </sup> The federal reimbursement category code \"03\" was previously a valid value used by some states on claims for their ACA adult expansion population. However, <a id=\"_Hlk103946431\"></a> CMS retired the \"03\" value in September 2020 and states are expected to use the \"01\" value for this population moving forward since the enhanced match rate for these enrollees is authorized under Title XIX.</p><p class=\"msword-paragraph\"> If states are populating these data elements correctly, claim records that link to beneficiaries enrolled in Title XIX Medicaid will be coded to indicate the expenditure is reportable on Form CMS-64. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-3\" id=\"footnote-ref-3\">[2]</a> </sup> </sup> Similarly, claim records that link to beneficiaries enrolled in Title XXI CHIP&mdash;including both M-CHIP and S-CHIP programs&mdash;will be coded to indicate the expenditure is reportable on Form CMS-21.</p><p class=\"msword-paragraph\"> Other TAF data elements can be used to summarize Medicaid and CHIP spending associated with certain services or benefit categories, including the state-assigned type of service code, the federally-assigned service category code, and the benefit type code. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-4\" id=\"footnote-ref-4\">[3]</a> </sup> </sup> However, those data elements will not necessarily line up with the CMS-64 or CMS-21 categories that states use to report expenditures for the purposes of federal reimbursement.</p><p class=\"msword-paragraph\"> In this data quality assessment, we evaluate the percentage of records in each claims file reported with a federal reimbursement category code that is consistent with the beneficiary&rsquo;s enrollment in the Medicaid or CHIP programs. We also evaluate the percentage of records in each claims file reported with a CMS-64 or CMS-21 category of service code consistent with the beneficiary&rsquo;s enrollment in the Medicaid or CHIP program.</p><ol> <li class=\"footnoteBody\" id=\"footnote-2\" value=\"1\"> <p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page, and a crosswalk of variable names can be found in the guide &ldquo;Production of the TAF Research Identifiable Files.&rdquo; </p> <p> <a href=\"#footnote-ref-2\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-3\" value=\"2\"> <p class=\"msword-footnote-text\"> More information about differences between expenditures in the TAF and the CMS-64 data can be found in the DQ Atlas single topic displays under the Expenditure Benchmarking topic area. </p> <p> <a href=\"#footnote-ref-3\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-4\" value=\"3\"> <p class=\"msword-footnote-text\"> More information on states with missing or invalid type of service code can be found in the DQ Atlas single topic displays for <a aria-label=\"View DQ Atlas single topic display for Type of Service - IP\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m52\">Type of Service - IP</a> , <a aria-label=\"View DQ Atlas single topic display for Type of Service - OT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m53\">Type of Service - OT</a> , <a aria-label=\"View DQ Atlas single topic display for Type of Service - LT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m54\">Type of Service - LT</a> , and <a aria-label=\"View DQ Atlas single topic display for Type of Service - RX\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m55\">Type of Service - RX</a> . For more information about the FASC code, see the methodology brief, &ldquo;Assigning TAF Records to a Federally Assigned Service Category,&rdquo; on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page. </p> <p> <a href=\"#footnote-ref-4\">&uarr;</a> </p> </li></ol>", "footnotes": [{"number": 2, "content": "<li class=\"footnoteBody\" id=\"footnote-2\" value=\"1\"><p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page, and a crosswalk of variable names can be found in the guide \u201cProduction of the TAF Research Identifiable Files.\u201d </p><p><a href=\"#footnote-ref-2\">\u2191</a></p></li>"}, {"number": 3, "content": "<li class=\"footnoteBody\" id=\"footnote-3\" value=\"2\"><p class=\"msword-footnote-text\"> More information about differences between expenditures in the TAF and the CMS-64 data can be found in the DQ Atlas single topic displays under the Expenditure Benchmarking topic area. </p><p><a href=\"#footnote-ref-3\">\u2191</a></p></li>"}, {"number": 4, "content": "<li class=\"footnoteBody\" id=\"footnote-4\" value=\"3\"><p class=\"msword-footnote-text\"> More information on states with missing or invalid type of service code can be found in the DQ Atlas single topic displays for <a aria-label=\"View DQ Atlas single topic display for Type of Service - IP\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m52\">Type of Service - IP</a> , <a aria-label=\"View DQ Atlas single topic display for Type of Service - OT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m53\">Type of Service - OT</a> , <a aria-label=\"View DQ Atlas single topic display for Type of Service - LT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m54\">Type of Service - LT</a> , and <a aria-label=\"View DQ Atlas single topic display for Type of Service - RX\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m55\">Type of Service - RX</a> . For more information about the FASC code, see the methodology brief, \u201cAssigning TAF Records to a Federally Assigned Service Category,\u201d on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page. </p><p><a href=\"#footnote-ref-4\">\u2191</a></p></li>"}]}, "methods": {"content": "<p class=\"msword-paragraph\"> We began by selecting all records from the IP, LT, OT, and RX claims files that represented Medicaid and S-CHIP fee-for-service (FFS), capitation, and supplemental payments based on the claim type code. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-2\" id=\"footnote-ref-2\">[4]</a> </sup> </sup> <sup> , </sup> <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-3\" id=\"footnote-ref-3\">[5]</a> </sup> </sup> We excluded managed care encounter records from the analysis because the payments recorded on those claims do not represent state expenditures and are not recorded on the CMS-64 or CMS-21. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-4\" id=\"footnote-ref-4\">[6]</a> </sup> </sup> We also excluded service tracking claims from the analysis because these records are lump-sum payments that that cannot be linked to an eligibility record. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-5\" id=\"footnote-ref-5\">[7]</a> </sup> </sup></p><p class=\"msword-paragraph\"> To determine whether the beneficiary was enrolled in Medicaid, M-CHIP, or S-CHIP on the date of service, we linked the claims records to the matching eligibility record using the unique beneficiary identifier coded on the claim (MSIS ID). We determined Medicaid, M-CHIP, and S-CHIP enrollment by examining the CHIP code on records in the TAF Demographic and Eligibility (DE) file from the month that corresponded to the date of service on the claim. We excluded from the analysis claims records with a missing or invalid beneficiary identifier. Additionally, we excluded claims that did not link to an eligibility record, as well as those that linked to an eligibility record but did not have a CHIP code populated (indicating the individual was enrolled in Medicaid or CHIP) during the date of service on the claim. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-6\" id=\"footnote-ref-6\">[8]</a> </sup> </sup></p><p class=\"msword-paragraph\"> Finally, we calculated the percentage of records in each file with a federal reimbursement category code consistent with the beneficiary&rsquo;s reported enrollment in Medicaid, M-CHIP, or S-CHIP. The expected coding for federal reimbursement category code based on CHIP code is shown in Table 2. Because Medicaid beneficiaries enrolled in an adult expansion eligibility group may have a different federal reimbursement category code than Medicaid beneficiaries not enrolled in such a group, we examined these two groups of Medicaid beneficiaries separately. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-7\" id=\"footnote-ref-7\">[9]</a> </sup> </sup> We also calculated the percentage of records with a CMS-64 or CMS-21 category of service code consistent with the beneficiary&rsquo;s enrollment in the Medicaid or CHIP program. The expected coding for CMS-64 and CMS-21 category of service code based on CHIP code is shown in Table 3.</p><p class=\"msword-table-title\"> Table 2. Expected coding for federal reimbursement category code</p><table aria-label=\"Table 2. Expected coding for federal reimbursement category code\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Enrollment type </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> CHIP code on eligibility record (CHIP_CD) </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Latest eligibility group on eligibility record (ELGBLTY_GRP_CD_LTST) </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Expected federal reimbursement category code on claim record </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Medicaid &ndash; Adult expansion group </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 1 </strong> (Medicaid) </p> </td> <td> <p class=\"msword-table-text-centered\"> <strong> 72 </strong> (Adult Group - Individuals at or below 133% FPL Age 19 through 64 - newly eligible for all states) </p> <p class=\"msword-table-text-centered\"> <strong> 73 </strong> (Adult Group - Individuals at or below 133% FPL Age 19 through 64- not newly eligible for non 1905z(3) states), </p> <p class=\"msword-table-text-centered\"> <strong> 74 </strong> (Adult Group - Individuals at or below 133% FPL Age 19 through 64 &ndash; not newly eligible parent/ caretaker relative(s) in 1905z(3) states), or </p> <p class=\"msword-table-text-centered\"> <strong> 75 </strong> (Adult Group - Individuals at or below 133% FPL Age 19 through 64- not newly eligible non-parent/ caretaker-relative(s) in 1905z(3) states) </p> </td> <td> <p class=\"msword-table-text-centered\"> <strong> 01 </strong> (Federal funding under Title XIX) or </p> <p class=\"msword-table-text-centered\"> <strong> 03 </strong> (Federal funding under ACA) <sup class=\"msword-superscript\"> a </sup> </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Medicaid &ndash; All other </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 1 </strong> (Medicaid) </p> </td> <td> <p class=\"msword-table-text-centered\"> Any valid code or null/missing, except: </p> <p class=\"msword-table-text-centered\"> <strong> 72, 73, 74, 75, </strong> or </p> <p class=\"msword-table-text-centered\"> <strong> 61-68 </strong> (CHIP eligibility groups) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 01 </strong> (Federal funding under Title XIX) </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> M-CHIP </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 2 </strong> (M-CHIP) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> N/A </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 02 </strong> (Federal funding under Title XXI) </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> S-CHIP </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 3 </strong> (S-CHIP) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> N/A </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 02 </strong> (Federal funding under Title XXI) </p> </td> </tr> </tbody></table><p class=\"msword-table-footnote\"> <sup class=\"msword-footnote-reference\"> a </sup> In this assessment, we consider both \"01\" and \"03\" to be consistent values for Medicaid-enrolled beneficiaries in the adult expansion eligibility groups. The value \"03\" (Federal funding under ACA) was retired as a valid value on September 30, 2020 and while the value is still present in the data before that date, we would expect to see relatively few claims with this value after that date.</p><p class=\"msword-table-footnote\"> ACA = Affordable Care Act; FPL = Federal Poverty Level; N/A = not available.</p><p class=\"msword-table-title\"> Table 3. Expected coding for CMS-64 and CMS-21 category of service codes</p><table aria-label=\"Table 3. Expected coding for CMS-64 and CMS-21 category of service codes\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> CHIP code on eligibility record (CHIP_CD) </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Expected CMS-64 category of service code on claims record </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Expected CMS-21 category of service code on claims record </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> <strong> 1 </strong> (Medicaid) </p> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> Any valid value for CMS-64 category of service </li> </ul> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> Field should be blank </li> </ul> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> <strong> 2 </strong> (M-CHIP) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Field should be blank </p> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> Any valid value for CMS-21 category of service </li> </ul> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> <strong> 3 </strong> (S-CHIP) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Field should be blank </p> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> Any valid value for CMS-21 category of service </li> </ul> </td> </tr> </tbody></table><p class=\"msword-header\"> Data quality assessment criteria</p><p class=\"msword-paragraph\"> We categorized each state as having low, medium, or high data quality concern for the federal reimbursement category code, depending on the percentage of records with a federal reimbursement category code consistent with the beneficiary&rsquo;s enrollment in the Medicaid, M-CHIP, or S-CHIP programs, as shown in Table 4.</p><p class=\"msword-table-title\"> Table 4. Criteria for DQ assessment of federal reimbursement category code</p><table aria-label=\"Table 4. Criteria for DQ assessment of federal reimbursement category code\" class=\"dq-assessment-table\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Percentage of claim lines with a federal reimbursement category code consistent with program enrollment </p> </th> <th class=\"msword-table-header-center dq-assessment-col\"> <p class=\"msword-table-header-center\"> DQ assessment </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &ge; 90 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level low\"> <p class=\"msword-table-text-centered\"> Low concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 80 percent &le; x &lt; 90 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level medium\"> <p class=\"msword-table-text-centered\"> Medium concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 50 percent &le; x &lt; 80 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level high\"> <p class=\"msword-table-text-centered\"> High concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &lt; 50 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level unusable\"> <p class=\"msword-table-text-centered\"> Unusable </p> </td> </tr> </tbody></table><p class=\"msword-paragraph\"> We categorized each state as having low, medium, or high data quality concern for the category of service code, depending on the percentage of records with a CMS-64 or CMS-21 category of service code consistent with the beneficiary&rsquo;s enrollment in the Medicaid, M-CHIP, or S-CHIP programs, as shown in Table 5. As shown in Table 3, only the CMS-64 or CMS-21 category of service code is expected to be populated on a single claim record. When both fields were populated on the same claim (even if one or both values were invalid), that record was inconsistent with enrollment in the Medicaid, M-CHIP, or S-CHIP programs for the purposes of this analysis.</p><p class=\"msword-table-title\"> Table 5. Criteria for DQ assessment of category of service codes</p><table aria-label=\"Table 5. Criteria for DQ assessment of category of service codes\" class=\"dq-assessment-table\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Percentage of claim lines with a CMS-64 category of service code or a CMS-21 category of service code consistent with program enrollment </p> </th> <th class=\"msword-table-header-center dq-assessment-col\"> <p class=\"msword-table-header-center\"> DQ assessment </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &ge; 90 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level low\"> <p class=\"msword-table-text-centered\"> Low concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 80 percent &le; x &lt; 90 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level medium\"> <p class=\"msword-table-text-centered\"> Medium concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 50 percent &le; x &lt; 80 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level high\"> <p class=\"msword-table-text-centered\"> High concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &lt; 50 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level unusable\"> <p class=\"msword-table-text-centered\"> Unusable </p> </td> </tr> </tbody></table><ol> <li class=\"footnoteBody\" id=\"footnote-2\" value=\"4\"> <p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page, and a crosswalk of variable names can be found in the guide &ldquo;Production of the TAF Research Identifiable Files.&rdquo; </p> <p> <a href=\"#footnote-ref-2\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-3\" value=\"5\"> <p class=\"msword-footnote-text\"> FFS claims representing Medicaid or M-CHIP services have a claim type code (CLM_TYPE_CD) value of 1, capitation payments have a claim type code value of 2, and supplemental payments have a claim type code value of 5. FFS claims representing S-CHIP benefits have a claim type code value of A, capitation payments have a claim type code value of B, and supplemental payments have a claim type code value of E. </p> <p> <a href=\"#footnote-ref-3\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-4\" value=\"6\"> <p class=\"msword-footnote-text\"> Payment data on managed care encounter records are redacted from the TAF RIFs. </p> <p> <a href=\"#footnote-ref-4\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-5\" value=\"7\"> <p class=\"msword-footnote-text\"> Managed care encounter records representing Medicaid or M-CHIP services have a claim type code value of 3 and service tracking claims have a claim type code value of 4. Managed care encounter records representing S-CHIP benefits have a claim type code value of C, and service tracking claims have a claim type code value of D. </p> <p> <a href=\"#footnote-ref-5\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-6\" value=\"8\"> <p class=\"msword-footnote-text\"> Once an individual is determined eligible for Medicaid, coverage is effective either on the date of application or the first day of the month of application. Benefits also may be covered retroactively for up to three months prior to the month of application if the individual would have been eligible during that period had he or she applied. States are required to update beneficiaries&rsquo; eligibility records in T-MSIS to reflect the retroactive coverage period. However, if a state did not update the eligibility record of a beneficiary to reflect the retroactive coverage period, enrollment information like CHIP code may be missing during the date of service on a paid claim. </p> <p> <a href=\"#footnote-ref-6\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-7\" value=\"9\"> <p class=\"msword-footnote-text\"> We determined the eligibility group by using ELGBLTY_GRP_CD_LTST, the most recent eligibility group reported for the beneficiary in the calendar year. </p> <p> <a href=\"#footnote-ref-7\">&uarr;</a> </p> </li></ol>", "footnotes": [{"number": 2, "content": "<li class=\"footnoteBody\" id=\"footnote-2\" value=\"4\"><p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page, and a crosswalk of variable names can be found in the guide \u201cProduction of the TAF Research Identifiable Files.\u201d </p><p><a href=\"#footnote-ref-2\">\u2191</a></p></li>"}, {"number": 3, "content": "<li class=\"footnoteBody\" id=\"footnote-3\" value=\"5\"><p class=\"msword-footnote-text\"> FFS claims representing Medicaid or M-CHIP services have a claim type code (CLM_TYPE_CD) value of 1, capitation payments have a claim type code value of 2, and supplemental payments have a claim type code value of 5. FFS claims representing S-CHIP benefits have a claim type code value of A, capitation payments have a claim type code value of B, and supplemental payments have a claim type code value of E. </p><p><a href=\"#footnote-ref-3\">\u2191</a></p></li>"}, {"number": 4, "content": "<li class=\"footnoteBody\" id=\"footnote-4\" value=\"6\"><p class=\"msword-footnote-text\"> Payment data on managed care encounter records are redacted from the TAF RIFs. </p><p><a href=\"#footnote-ref-4\">\u2191</a></p></li>"}, {"number": 5, "content": "<li class=\"footnoteBody\" id=\"footnote-5\" value=\"7\"><p class=\"msword-footnote-text\"> Managed care encounter records representing Medicaid or M-CHIP services have a claim type code value of 3 and service tracking claims have a claim type code value of 4. Managed care encounter records representing S-CHIP benefits have a claim type code value of C, and service tracking claims have a claim type code value of D. </p><p><a href=\"#footnote-ref-5\">\u2191</a></p></li>"}, {"number": 6, "content": "<li class=\"footnoteBody\" id=\"footnote-6\" value=\"8\"><p class=\"msword-footnote-text\"> Once an individual is determined eligible for Medicaid, coverage is effective either on the date of application or the first day of the month of application. Benefits also may be covered retroactively for up to three months prior to the month of application if the individual would have been eligible during that period had he or she applied. States are required to update beneficiaries\u2019 eligibility records in T-MSIS to reflect the retroactive coverage period. However, if a state did not update the eligibility record of a beneficiary to reflect the retroactive coverage period, enrollment information like CHIP code may be missing during the date of service on a paid claim. </p><p><a href=\"#footnote-ref-6\">\u2191</a></p></li>"}, {"number": 7, "content": "<li class=\"footnoteBody\" id=\"footnote-7\" value=\"9\"><p class=\"msword-footnote-text\"> We determined the eligibility group by using ELGBLTY_GRP_CD_LTST, the most recent eligibility group reported for the beneficiary in the calendar year. </p><p><a href=\"#footnote-ref-7\">\u2191</a></p></li>"}]}, "summary": {"content": "<p>The federal reimbursement category code indicates whether a claim represents state expenditures that qualify for federal matching funds under Title XIX (Medicaid), Title XXI (CHIP), or other legislation. This analysis examines the extent to which records in the OT file are reported with a federal reimbursement category code consistent with the beneficiary's enrollment in the Medicaid or CHIP program.</p>", "footnotes": []}, "originalIssueBriefId": "5221", "relatedTopics": [{"measureId": 111, "measureName": "Category of Service Code - IP", "groupId": 12, "groupName": "Financial Reporting", "order": 0}, {"measureId": 112, "measureName": "Category of Service Code - LT", "groupId": 12, "groupName": "Financial Reporting", "order": 1}, {"measureId": 113, "measureName": "Category of Service Code - OT", "groupId": 12, "groupName": "Financial Reporting", "order": 2}, {"measureId": 114, "measureName": "Category of Service Code - RX", "groupId": 12, "groupName": "Financial Reporting", "order": 3}, {"measureId": 115, "measureName": "Federal Reimbursement Category Code - IP", "groupId": 12, "groupName": "Financial Reporting", "order": 4}, {"measureId": 116, "measureName": "Federal Reimbursement Category Code - LT", "groupId": 12, "groupName": "Financial Reporting", "order": 5}, {"measureId": 118, "measureName": "Federal Reimbursement Category Code - RX", "groupId": 12, "groupName": "Financial Reporting", "order": 7}]}
118
{"measureId": 118, "measureName": "Federal Reimbursement Category Code - RX", "groupId": 12, "groupName": "Financial Reporting", "pdfVersionLink": "downloads/background-and-methods/TAF-DQ-Fed-Srvc-Reimb-Cd-RX.pdf", "background": {"content": "<p class=\"msword-paragraph\"> <a id=\"_Hlk30592933\"></a> <a id=\"_Hlk95402275\"></a> Medicaid and the Children&rsquo;s Health Insurance Program (CHIP) are joint state-federal medical assistance programs in which the state administers the program and pays providers or health plans directly for covered services, and the federal government reimburses a set percentage of the state&rsquo;s expenditures (referred to as the \"federal match\"). Because the federal government applies different federal matching rates to Medicaid and CHIP beneficiaries, states report Medicaid and CHIP expenditure data separately.</p><p class=\"msword-paragraph\"> To claim federal matching funds for their medical assistance programs, states report aggregate expenditure data for Medicaid beneficiaries covered under Title XIX of the Social Security Act to the Centers for Medicare &amp; Medicaid Services (CMS) on Form CMS-64, <em> Quarterly Medicaid Statement of Expenditures. </em> States report aggregate expenditure data for the CHIP beneficiaries covered under Title XXI of the Social Security Act on Form CMS-21, <em> Quarterly CHIP Statement of Expenditures </em> . States may cover children using CHIP funds by expanding their Medicaid programs (called \"Medicaid expansion CHIP,\" or M-CHIP), creating a program separate from their existing Medicaid programs (called \"separate CHIP,\" or S-CHIP), or adopting a combination of both approaches. Expenditures for both M-CHIP and S-CHIP beneficiaries, which qualify for the higher CHIP federal match rate, are reported on Form CMS-21 and not Form CMS-64.</p><p class=\"msword-paragraph\"> There are three data elements in the T-MSIS Analytic Files (TAF) inpatient (IP), long-term care (LT), other services (OT), and pharmacy (RX) files that contain information about how states report Medicaid and CHIP expenditures to claim federal matching funds: the federal reimbursement category code, the CMS-64 category of service code, and the CMS-21 category of service code (Table 1). <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-2\" id=\"footnote-ref-2\">[1]</a> </sup> </sup> The federal reimbursement category code indicates whether the expenditure was reimbursed under Title XIX, Title XXI, the Affordable Care Act (ACA), or other legislation. As noted earlier, if the expenditure was covered by Title XIX of the Social Security Act, it should be reported on Form CMS-64; if the expenditure was covered by Title XXI of the Social Security Act it should be reported on Form CMS-21. The CMS-64 category of service code indicates the specific category of service on Form CMS-64 into which the state will report the Medicaid expenditures associated with a paid claim. The CMS-21 category of service code indicates the specific category of service on Form CMS-21 into which the state will report the CHIP expenditures associated with a paid claim.</p><p class=\"msword-table-title\"> Table 1. TAF variables that classify expenditures into federal reimbursement categories</p><table aria-label=\"Table 1. TAF variables that classify expenditures into federal reimbursement categories\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Variable </p> </th> <th> <p class=\"msword-table-header-center\"> TAF data element name </p> <p class=\"msword-table-header-center\"> (TAF RIF name in parentheses if different) </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> IP, LT, OT, and RX records expected to have non-missing values </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Description </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Federal reimbursement category code </p> </td> <td> <p class=\"msword-table-text-centered\"> CMS_64_FED_REIMBRSMT_CTGRY_CD </p> <p class=\"msword-table-text-centered\"> (CMS_64_FED_CTGRY_CD) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> All records </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> This code indicates whether the claim was matched with federal funding under Title XIX (value of &lsquo;01&rsquo;), Title XXI (&lsquo;02&rsquo;), the Affordable Care Act (&lsquo;03&rsquo;), <sup class=\"msword-superscript\"> a </sup> or federal funding under other legislation (&lsquo;04&rsquo;). </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> CMS-64 category of service code </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> XIX_SRVC_CTGRY_CD </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Only records representing expenditures that the state will report on the CMS-64, which should link to beneficiaries enrolled in non-CHIP Medicaid </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> A four-digit code (from 001A to 0050) indicating the line on the Form CMS-64 on which the state reported the expenditures associated with the claim. The Form CMS-64 is used to report expenditures that qualify for federal matching funds under Title XXI. A full list of the category of service and definition for each line can be found at <a aria-label=\"View Categories of service in the CMS-64 on Medicaid.gov\" href=\"https://www.medicaid.gov/medicaid/downloads/cms-649-base-category-of-services-definition-2-14.pdf\">https://www.medicaid.gov/medicaid/downloads/cms-649-base-category-of-services-definition-2-14.pdf</a> . </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> CMS-21 category of service code </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> XIX_SRVC_CTGRY_CD </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Only records representing expenditures that the state will report on the CMS-21, which should link to beneficiaries enrolled in Medicaid-expansion CHIP or Separate CHIP </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> A three-digit code (from 01A to 35B) indicating the category of service (or line) on the Form CMS-21 on which the state reported the expenditures associated with the claim. The Form CMS-21 is used to report expenditures that qualify for federal matching funds under Title XXI. A full list of the category of service and definition for each line can be found at <a aria-label=\"View MBES Category of Service Definitions for the CMS-21 Base Form\" href=\"https://www.medicaid.gov/medicaid/downloads/cms-21-base-category-of-services-definition-2-14.pdf\">https://www.medicaid.gov/medicaid/downloads/cms-21-base-category-of-services-definition-2-14.pdf</a> . </p> </td> </tr> </tbody></table><p class=\"msword-table-footnote\"> <sup class=\"msword-footnote-reference\"> a </sup> The federal reimbursement category code \"03\" was previously a valid value used by some states on claims for their ACA adult expansion population. However, <a id=\"_Hlk103946431\"></a> CMS retired the \"03\" value in September 2020 and states are expected to use the \"01\" value for this population moving forward since the enhanced match rate for these enrollees is authorized under Title XIX.</p><p class=\"msword-paragraph\"> If states are populating these data elements correctly, claim records that link to beneficiaries enrolled in Title XIX Medicaid will be coded to indicate the expenditure is reportable on Form CMS-64. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-3\" id=\"footnote-ref-3\">[2]</a> </sup> </sup> Similarly, claim records that link to beneficiaries enrolled in Title XXI CHIP&mdash;including both M-CHIP and S-CHIP programs&mdash;will be coded to indicate the expenditure is reportable on Form CMS-21.</p><p class=\"msword-paragraph\"> Other TAF data elements can be used to summarize Medicaid and CHIP spending associated with certain services or benefit categories, including the state-assigned type of service code, the federally-assigned service category code, and the benefit type code. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-4\" id=\"footnote-ref-4\">[3]</a> </sup> </sup> However, those data elements will not necessarily line up with the CMS-64 or CMS-21 categories that states use to report expenditures for the purposes of federal reimbursement.</p><p class=\"msword-paragraph\"> In this data quality assessment, we evaluate the percentage of records in each claims file reported with a federal reimbursement category code that is consistent with the beneficiary&rsquo;s enrollment in the Medicaid or CHIP programs. We also evaluate the percentage of records in each claims file reported with a CMS-64 or CMS-21 category of service code consistent with the beneficiary&rsquo;s enrollment in the Medicaid or CHIP program.</p><ol> <li class=\"footnoteBody\" id=\"footnote-2\" value=\"1\"> <p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page, and a crosswalk of variable names can be found in the guide &ldquo;Production of the TAF Research Identifiable Files.&rdquo; </p> <p> <a href=\"#footnote-ref-2\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-3\" value=\"2\"> <p class=\"msword-footnote-text\"> More information about differences between expenditures in the TAF and the CMS-64 data can be found in the DQ Atlas single topic displays under the Expenditure Benchmarking topic area. </p> <p> <a href=\"#footnote-ref-3\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-4\" value=\"3\"> <p class=\"msword-footnote-text\"> More information on states with missing or invalid type of service code can be found in the DQ Atlas single topic displays for <a aria-label=\"View DQ Atlas single topic display for Type of Service - IP\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m52\">Type of Service - IP</a> , <a aria-label=\"View DQ Atlas single topic display for Type of Service - OT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m53\">Type of Service - OT</a> , <a aria-label=\"View DQ Atlas single topic display for Type of Service - LT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m54\">Type of Service - LT</a> , and <a aria-label=\"View DQ Atlas single topic display for Type of Service - RX\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m55\">Type of Service - RX</a> . For more information about the FASC code, see the methodology brief, &ldquo;Assigning TAF Records to a Federally Assigned Service Category,&rdquo; on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page. </p> <p> <a href=\"#footnote-ref-4\">&uarr;</a> </p> </li></ol>", "footnotes": [{"number": 2, "content": "<li class=\"footnoteBody\" id=\"footnote-2\" value=\"1\"><p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page, and a crosswalk of variable names can be found in the guide \u201cProduction of the TAF Research Identifiable Files.\u201d </p><p><a href=\"#footnote-ref-2\">\u2191</a></p></li>"}, {"number": 3, "content": "<li class=\"footnoteBody\" id=\"footnote-3\" value=\"2\"><p class=\"msword-footnote-text\"> More information about differences between expenditures in the TAF and the CMS-64 data can be found in the DQ Atlas single topic displays under the Expenditure Benchmarking topic area. </p><p><a href=\"#footnote-ref-3\">\u2191</a></p></li>"}, {"number": 4, "content": "<li class=\"footnoteBody\" id=\"footnote-4\" value=\"3\"><p class=\"msword-footnote-text\"> More information on states with missing or invalid type of service code can be found in the DQ Atlas single topic displays for <a aria-label=\"View DQ Atlas single topic display for Type of Service - IP\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m52\">Type of Service - IP</a> , <a aria-label=\"View DQ Atlas single topic display for Type of Service - OT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m53\">Type of Service - OT</a> , <a aria-label=\"View DQ Atlas single topic display for Type of Service - LT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m54\">Type of Service - LT</a> , and <a aria-label=\"View DQ Atlas single topic display for Type of Service - RX\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g5m55\">Type of Service - RX</a> . For more information about the FASC code, see the methodology brief, \u201cAssigning TAF Records to a Federally Assigned Service Category,\u201d on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page. </p><p><a href=\"#footnote-ref-4\">\u2191</a></p></li>"}]}, "methods": {"content": "<p class=\"msword-paragraph\"> We began by selecting all records from the IP, LT, OT, and RX claims files that represented Medicaid and S-CHIP fee-for-service (FFS), capitation, and supplemental payments based on the claim type code. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-2\" id=\"footnote-ref-2\">[4]</a> </sup> </sup> <sup> , </sup> <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-3\" id=\"footnote-ref-3\">[5]</a> </sup> </sup> We excluded managed care encounter records from the analysis because the payments recorded on those claims do not represent state expenditures and are not recorded on the CMS-64 or CMS-21. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-4\" id=\"footnote-ref-4\">[6]</a> </sup> </sup> We also excluded service tracking claims from the analysis because these records are lump-sum payments that that cannot be linked to an eligibility record. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-5\" id=\"footnote-ref-5\">[7]</a> </sup> </sup></p><p class=\"msword-paragraph\"> To determine whether the beneficiary was enrolled in Medicaid, M-CHIP, or S-CHIP on the date of service, we linked the claims records to the matching eligibility record using the unique beneficiary identifier coded on the claim (MSIS ID). We determined Medicaid, M-CHIP, and S-CHIP enrollment by examining the CHIP code on records in the TAF Demographic and Eligibility (DE) file from the month that corresponded to the date of service on the claim. We excluded from the analysis claims records with a missing or invalid beneficiary identifier. Additionally, we excluded claims that did not link to an eligibility record, as well as those that linked to an eligibility record but did not have a CHIP code populated (indicating the individual was enrolled in Medicaid or CHIP) during the date of service on the claim. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-6\" id=\"footnote-ref-6\">[8]</a> </sup> </sup></p><p class=\"msword-paragraph\"> Finally, we calculated the percentage of records in each file with a federal reimbursement category code consistent with the beneficiary&rsquo;s reported enrollment in Medicaid, M-CHIP, or S-CHIP. The expected coding for federal reimbursement category code based on CHIP code is shown in Table 2. Because Medicaid beneficiaries enrolled in an adult expansion eligibility group may have a different federal reimbursement category code than Medicaid beneficiaries not enrolled in such a group, we examined these two groups of Medicaid beneficiaries separately. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-7\" id=\"footnote-ref-7\">[9]</a> </sup> </sup> We also calculated the percentage of records with a CMS-64 or CMS-21 category of service code consistent with the beneficiary&rsquo;s enrollment in the Medicaid or CHIP program. The expected coding for CMS-64 and CMS-21 category of service code based on CHIP code is shown in Table 3.</p><p class=\"msword-table-title\"> Table 2. Expected coding for federal reimbursement category code</p><table aria-label=\"Table 2. Expected coding for federal reimbursement category code\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Enrollment type </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> CHIP code on eligibility record (CHIP_CD) </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Latest eligibility group on eligibility record (ELGBLTY_GRP_CD_LTST) </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Expected federal reimbursement category code on claim record </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Medicaid &ndash; Adult expansion group </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 1 </strong> (Medicaid) </p> </td> <td> <p class=\"msword-table-text-centered\"> <strong> 72 </strong> (Adult Group - Individuals at or below 133% FPL Age 19 through 64 - newly eligible for all states) </p> <p class=\"msword-table-text-centered\"> <strong> 73 </strong> (Adult Group - Individuals at or below 133% FPL Age 19 through 64- not newly eligible for non 1905z(3) states), </p> <p class=\"msword-table-text-centered\"> <strong> 74 </strong> (Adult Group - Individuals at or below 133% FPL Age 19 through 64 &ndash; not newly eligible parent/ caretaker relative(s) in 1905z(3) states), or </p> <p class=\"msword-table-text-centered\"> <strong> 75 </strong> (Adult Group - Individuals at or below 133% FPL Age 19 through 64- not newly eligible non-parent/ caretaker-relative(s) in 1905z(3) states) </p> </td> <td> <p class=\"msword-table-text-centered\"> <strong> 01 </strong> (Federal funding under Title XIX) or </p> <p class=\"msword-table-text-centered\"> <strong> 03 </strong> (Federal funding under ACA) <sup class=\"msword-superscript\"> a </sup> </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Medicaid &ndash; All other </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 1 </strong> (Medicaid) </p> </td> <td> <p class=\"msword-table-text-centered\"> Any valid code or null/missing, except: </p> <p class=\"msword-table-text-centered\"> <strong> 72, 73, 74, 75, </strong> or </p> <p class=\"msword-table-text-centered\"> <strong> 61-68 </strong> (CHIP eligibility groups) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 01 </strong> (Federal funding under Title XIX) </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> M-CHIP </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 2 </strong> (M-CHIP) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> N/A </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 02 </strong> (Federal funding under Title XXI) </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> S-CHIP </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 3 </strong> (S-CHIP) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> N/A </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> <strong> 02 </strong> (Federal funding under Title XXI) </p> </td> </tr> </tbody></table><p class=\"msword-table-footnote\"> <sup class=\"msword-footnote-reference\"> a </sup> In this assessment, we consider both \"01\" and \"03\" to be consistent values for Medicaid-enrolled beneficiaries in the adult expansion eligibility groups. The value \"03\" (Federal funding under ACA) was retired as a valid value on September 30, 2020 and while the value is still present in the data before that date, we would expect to see relatively few claims with this value after that date.</p><p class=\"msword-table-footnote\"> ACA = Affordable Care Act; FPL = Federal Poverty Level; N/A = not available.</p><p class=\"msword-table-title\"> Table 3. Expected coding for CMS-64 and CMS-21 category of service codes</p><table aria-label=\"Table 3. Expected coding for CMS-64 and CMS-21 category of service codes\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> CHIP code on eligibility record (CHIP_CD) </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Expected CMS-64 category of service code on claims record </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Expected CMS-21 category of service code on claims record </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> <strong> 1 </strong> (Medicaid) </p> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> Any valid value for CMS-64 category of service </li> </ul> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> Field should be blank </li> </ul> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> <strong> 2 </strong> (M-CHIP) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Field should be blank </p> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> Any valid value for CMS-21 category of service </li> </ul> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> <strong> 3 </strong> (S-CHIP) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Field should be blank </p> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> Any valid value for CMS-21 category of service </li> </ul> </td> </tr> </tbody></table><p class=\"msword-header\"> Data quality assessment criteria</p><p class=\"msword-paragraph\"> We categorized each state as having low, medium, or high data quality concern for the federal reimbursement category code, depending on the percentage of records with a federal reimbursement category code consistent with the beneficiary&rsquo;s enrollment in the Medicaid, M-CHIP, or S-CHIP programs, as shown in Table 4.</p><p class=\"msword-table-title\"> Table 4. Criteria for DQ assessment of federal reimbursement category code</p><table aria-label=\"Table 4. Criteria for DQ assessment of federal reimbursement category code\" class=\"dq-assessment-table\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Percentage of claim lines with a federal reimbursement category code consistent with program enrollment </p> </th> <th class=\"msword-table-header-center dq-assessment-col\"> <p class=\"msword-table-header-center\"> DQ assessment </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &ge; 90 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level low\"> <p class=\"msword-table-text-centered\"> Low concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 80 percent &le; x &lt; 90 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level medium\"> <p class=\"msword-table-text-centered\"> Medium concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 50 percent &le; x &lt; 80 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level high\"> <p class=\"msword-table-text-centered\"> High concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &lt; 50 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level unusable\"> <p class=\"msword-table-text-centered\"> Unusable </p> </td> </tr> </tbody></table><p class=\"msword-paragraph\"> We categorized each state as having low, medium, or high data quality concern for the category of service code, depending on the percentage of records with a CMS-64 or CMS-21 category of service code consistent with the beneficiary&rsquo;s enrollment in the Medicaid, M-CHIP, or S-CHIP programs, as shown in Table 5. As shown in Table 3, only the CMS-64 or CMS-21 category of service code is expected to be populated on a single claim record. When both fields were populated on the same claim (even if one or both values were invalid), that record was inconsistent with enrollment in the Medicaid, M-CHIP, or S-CHIP programs for the purposes of this analysis.</p><p class=\"msword-table-title\"> Table 5. Criteria for DQ assessment of category of service codes</p><table aria-label=\"Table 5. Criteria for DQ assessment of category of service codes\" class=\"dq-assessment-table\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Percentage of claim lines with a CMS-64 category of service code or a CMS-21 category of service code consistent with program enrollment </p> </th> <th class=\"msword-table-header-center dq-assessment-col\"> <p class=\"msword-table-header-center\"> DQ assessment </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &ge; 90 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level low\"> <p class=\"msword-table-text-centered\"> Low concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 80 percent &le; x &lt; 90 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level medium\"> <p class=\"msword-table-text-centered\"> Medium concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 50 percent &le; x &lt; 80 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level high\"> <p class=\"msword-table-text-centered\"> High concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &lt; 50 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level unusable\"> <p class=\"msword-table-text-centered\"> Unusable </p> </td> </tr> </tbody></table><ol> <li class=\"footnoteBody\" id=\"footnote-2\" value=\"4\"> <p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page, and a crosswalk of variable names can be found in the guide &ldquo;Production of the TAF Research Identifiable Files.&rdquo; </p> <p> <a href=\"#footnote-ref-2\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-3\" value=\"5\"> <p class=\"msword-footnote-text\"> FFS claims representing Medicaid or M-CHIP services have a claim type code (CLM_TYPE_CD) value of 1, capitation payments have a claim type code value of 2, and supplemental payments have a claim type code value of 5. FFS claims representing S-CHIP benefits have a claim type code value of A, capitation payments have a claim type code value of B, and supplemental payments have a claim type code value of E. </p> <p> <a href=\"#footnote-ref-3\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-4\" value=\"6\"> <p class=\"msword-footnote-text\"> Payment data on managed care encounter records are redacted from the TAF RIFs. </p> <p> <a href=\"#footnote-ref-4\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-5\" value=\"7\"> <p class=\"msword-footnote-text\"> Managed care encounter records representing Medicaid or M-CHIP services have a claim type code value of 3 and service tracking claims have a claim type code value of 4. Managed care encounter records representing S-CHIP benefits have a claim type code value of C, and service tracking claims have a claim type code value of D. </p> <p> <a href=\"#footnote-ref-5\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-6\" value=\"8\"> <p class=\"msword-footnote-text\"> Once an individual is determined eligible for Medicaid, coverage is effective either on the date of application or the first day of the month of application. Benefits also may be covered retroactively for up to three months prior to the month of application if the individual would have been eligible during that period had he or she applied. States are required to update beneficiaries&rsquo; eligibility records in T-MSIS to reflect the retroactive coverage period. However, if a state did not update the eligibility record of a beneficiary to reflect the retroactive coverage period, enrollment information like CHIP code may be missing during the date of service on a paid claim. </p> <p> <a href=\"#footnote-ref-6\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-7\" value=\"9\"> <p class=\"msword-footnote-text\"> We determined the eligibility group by using ELGBLTY_GRP_CD_LTST, the most recent eligibility group reported for the beneficiary in the calendar year. </p> <p> <a href=\"#footnote-ref-7\">&uarr;</a> </p> </li></ol>", "footnotes": [{"number": 2, "content": "<li class=\"footnoteBody\" id=\"footnote-2\" value=\"4\"><p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources</a> page, and a crosswalk of variable names can be found in the guide \u201cProduction of the TAF Research Identifiable Files.\u201d </p><p><a href=\"#footnote-ref-2\">\u2191</a></p></li>"}, {"number": 3, "content": "<li class=\"footnoteBody\" id=\"footnote-3\" value=\"5\"><p class=\"msword-footnote-text\"> FFS claims representing Medicaid or M-CHIP services have a claim type code (CLM_TYPE_CD) value of 1, capitation payments have a claim type code value of 2, and supplemental payments have a claim type code value of 5. FFS claims representing S-CHIP benefits have a claim type code value of A, capitation payments have a claim type code value of B, and supplemental payments have a claim type code value of E. </p><p><a href=\"#footnote-ref-3\">\u2191</a></p></li>"}, {"number": 4, "content": "<li class=\"footnoteBody\" id=\"footnote-4\" value=\"6\"><p class=\"msword-footnote-text\"> Payment data on managed care encounter records are redacted from the TAF RIFs. </p><p><a href=\"#footnote-ref-4\">\u2191</a></p></li>"}, {"number": 5, "content": "<li class=\"footnoteBody\" id=\"footnote-5\" value=\"7\"><p class=\"msword-footnote-text\"> Managed care encounter records representing Medicaid or M-CHIP services have a claim type code value of 3 and service tracking claims have a claim type code value of 4. Managed care encounter records representing S-CHIP benefits have a claim type code value of C, and service tracking claims have a claim type code value of D. </p><p><a href=\"#footnote-ref-5\">\u2191</a></p></li>"}, {"number": 6, "content": "<li class=\"footnoteBody\" id=\"footnote-6\" value=\"8\"><p class=\"msword-footnote-text\"> Once an individual is determined eligible for Medicaid, coverage is effective either on the date of application or the first day of the month of application. Benefits also may be covered retroactively for up to three months prior to the month of application if the individual would have been eligible during that period had he or she applied. States are required to update beneficiaries\u2019 eligibility records in T-MSIS to reflect the retroactive coverage period. However, if a state did not update the eligibility record of a beneficiary to reflect the retroactive coverage period, enrollment information like CHIP code may be missing during the date of service on a paid claim. </p><p><a href=\"#footnote-ref-6\">\u2191</a></p></li>"}, {"number": 7, "content": "<li class=\"footnoteBody\" id=\"footnote-7\" value=\"9\"><p class=\"msword-footnote-text\"> We determined the eligibility group by using ELGBLTY_GRP_CD_LTST, the most recent eligibility group reported for the beneficiary in the calendar year. </p><p><a href=\"#footnote-ref-7\">\u2191</a></p></li>"}]}, "summary": {"content": "<p>The federal reimbursement category code indicates whether a claim represents state expenditures that qualify for federal matching funds under Title XIX (Medicaid), Title XXI (CHIP), or other legislation. This analysis examines the extent to which records in the RX file are reported with a federal reimbursement category code consistent with the beneficiary's enrollment in the Medicaid or CHIP program.</p>", "footnotes": []}, "originalIssueBriefId": "5221", "relatedTopics": [{"measureId": 111, "measureName": "Category of Service Code - IP", "groupId": 12, "groupName": "Financial Reporting", "order": 0}, {"measureId": 112, "measureName": "Category of Service Code - LT", "groupId": 12, "groupName": "Financial Reporting", "order": 1}, {"measureId": 113, "measureName": "Category of Service Code - OT", "groupId": 12, "groupName": "Financial Reporting", "order": 2}, {"measureId": 114, "measureName": "Category of Service Code - RX", "groupId": 12, "groupName": "Financial Reporting", "order": 3}, {"measureId": 115, "measureName": "Federal Reimbursement Category Code - IP", "groupId": 12, "groupName": "Financial Reporting", "order": 4}, {"measureId": 116, "measureName": "Federal Reimbursement Category Code - LT", "groupId": 12, "groupName": "Financial Reporting", "order": 5}, {"measureId": 117, "measureName": "Federal Reimbursement Category Code - OT", "groupId": 12, "groupName": "Financial Reporting", "order": 6}]}
119
{"measureId": 119, "measureName": "Primary Language", "groupId": 3, "groupName": "Beneficiary Information", "pdfVersionLink": "downloads/background-and-methods/TAF-DQ-Primary-Lang.pdf", "background": {"content": "<p class=\"msword-paragraph\"> <a id=\"_Hlk30592933\"></a> The T-MSIS Analytic Files (TAF) are research-optimized data on beneficiaries enrolled in Medicaid and the Children&rsquo;s Health Insurance Program (CHIP). The Annual Demographic and Eligibility (DE) file contains information on beneficiary demographic characteristics, including primary or preferred language and English language proficiency. States often gather this information via applications for Medicaid and CHIP benefits. However, states may vary in whether and how they ask these questions because language information is not required for eligibility determination. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-2\" id=\"footnote-ref-2\">[1]</a> </sup> </sup> <a id=\"_Hlk101268128\"></a> Although the U.S. Department of Health and Human Services (HHS) recommends that states give at minimum two language options other than English ( <em> Spanish </em> or <em> Other language </em> ), some states give applicants a range of languages from which to choose.</p><p class=\"msword-paragraph\"> States use one data element to submit information on a beneficiary&rsquo;s language preference in T-MSIS: the primary language code, <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-3\" id=\"footnote-ref-3\">[2]</a> </sup> </sup> which uses a valid value set of approximately 500 three-letter categories from the International Organization for Standardization (ISO) codes for the representation of names of languages, Part 2 (ISO 639-2). <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-4\" id=\"footnote-ref-4\">[3]</a> </sup> </sup> When eligibility records are created in TAF, this source data element is used to create two TAF data elements: (1) the primary language code, <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-5\" id=\"footnote-ref-5\">[4]</a> </sup> </sup> which takes on all of the ISO 639-2 language codes as valid values; and (2) the constructed primary language group code, with 14 valid values. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-6\" id=\"footnote-ref-6\">[5]</a> </sup> </sup> States vary in whether they report the English ISO language code or leave the data element blank when a beneficiary&rsquo;s primary language is English.</p><p class=\"msword-paragraph\"> In addition, states use one data element to submit information on how well a beneficiary speaks English: the English language proficiency code, <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-7\" id=\"footnote-ref-7\">[6]</a> </sup> </sup> which uses a four-point scale (no spoken proficiency, does not speak well, speaks well, speaks very well).</p><p class=\"msword-paragraph\"> This analysis assesses the usability of the constructed primary language group code <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-8\" id=\"footnote-ref-8\">[7]</a> </sup> </sup> by measuring the extent to which certain language categories (English, Spanish, Other) align with an external benchmark, the American Community Survey (ACS). We also assess the usability of the English language proficiency code among beneficiaries with Spanish or Other primary language in TAF by measuring the extent to which certain English proficiency categories (\"not well\" or \"no spoken proficiency\") differ substantively from the ACS.</p><ol> <li class=\"footnoteBody\" id=\"footnote-2\" value=\"1\"> <p class=\"msword-footnote-text\"> More information about the collection of race, ethnicity, and language data in Medicaid Applications is available at <a aria-label=\"View Issue Brief: Collection of Race, Ethnicity, Language (REL) Data in Medicaid Applications\" href=\"https://www.shvs.org/wp-content/uploads/2021/05/SHVS-50-State-Review-EDITED.pdf\">https://www.shvs.org/wp-content/uploads/2021/05/SHVS-50-State-Review-EDITED.pdf</a> . </p> <p> <a href=\"#footnote-ref-2\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-3\" value=\"2\"> <p class=\"msword-footnote-text\"> The definition of the T-MSIS primary language code (and in turn, the TAF language code and constructed primary language group code) changed slightly in 2022 to represent \"the individual&rsquo;s preferred spoken or written language\" (which may or may not be English) rather than the individual&rsquo;s language \"other than English.\" The updated definition reflects what already had been observed in T-MSIS data: most states report a majority of eligibility records with English as the primary language code, suggesting they were not following the original variable definition but rather reporting what they gather on Medicaid applications, which offer English as an option for primary language. </p> <p> <a href=\"#footnote-ref-3\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-4\" value=\"3\"> <p class=\"msword-footnote-text\"> For a list of valid values, see Codes for Representation of Names of Languages at <a aria-label=\"View ISO Codes for Representation of Names of Languages\" href=\"https://www.loc.gov/standards/iso639-2/php/code_list.php\">https://www.loc.gov/standards/iso639-2/php/code_list.php</a> . The ISO reviews its code sets every five years; the ISO 639-2 lifecycle can be viewed at <a aria-label=\"View ISO 639-2 Standard Life Cycle\" href=\"https://www.iso.org/standard/4767.html\">https://www.iso.org/standard/4767.html</a> . </p> <p> <a href=\"#footnote-ref-4\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-5\" value=\"4\"> <p class=\"msword-footnote-text\"> In the internal version of the TAF data within the CMCS data environment, the primary language code is stored as \"Language (Other Than English) Code\" (OTHR_LANG_HOME_CD).\" </p> <p> <a href=\"#footnote-ref-5\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-6\" value=\"5\"> <p class=\"msword-footnote-text\"> In the internal version of the TAF data within the CMCS data environment, the constructed primary language group code is stored as \"Constructed Primary Language (Other Than English) Group Code\" (PRMRY_LANG_FLAG).\" The categories in the constructed primary language group code come from the Social Security Administration Master Beneficiary Record variable for preferred written language. Although English is a valid value, it is widely accepted that users should assume English is the preferred language if the field is left blank. </p> <p> <a href=\"#footnote-ref-6\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-7\" value=\"6\"> <p class=\"msword-footnote-text\"> The name of the T-MSIS English language proficiency code (and in turn, the TAF English language proficiency code) changed slightly in 2022 to clarify that states should capture the level of spoken English proficiency regardless of whether it is the individual&rsquo;s preferred spoken or written language. Previously, it was unclear whether the field should be populated for beneficiaries whose primary language was not English. The updated name reflects what states likely already gather on Medicaid applications. </p> <p> <a href=\"#footnote-ref-7\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-8\" value=\"7\"> <p class=\"msword-footnote-text\"> We were not able to assess the validity of each language value available under the language code. Users interested in the level of specificity offered by the language code should adapt the methods used for this data quality assessment using the three-letter values for the languages of interest. </p> <p> <a href=\"#footnote-ref-8\">&uarr;</a> </p> </li></ol>", "footnotes": [{"number": 2, "content": "<li class=\"footnoteBody\" id=\"footnote-2\" value=\"1\"><p class=\"msword-footnote-text\"> More information about the collection of race, ethnicity, and language data in Medicaid Applications is available at <a aria-label=\"View Issue Brief: Collection of Race, Ethnicity, Language (REL) Data in Medicaid Applications\" href=\"https://www.shvs.org/wp-content/uploads/2021/05/SHVS-50-State-Review-EDITED.pdf\">https://www.shvs.org/wp-content/uploads/2021/05/SHVS-50-State-Review-EDITED.pdf</a> . </p><p><a href=\"#footnote-ref-2\">\u2191</a></p></li>"}, {"number": 3, "content": "<li class=\"footnoteBody\" id=\"footnote-3\" value=\"2\"><p class=\"msword-footnote-text\"> The definition of the T-MSIS primary language code (and in turn, the TAF language code and constructed primary language group code) changed slightly in 2022 to represent \"the individual\u2019s preferred spoken or written language\" (which may or may not be English) rather than the individual\u2019s language \"other than English.\" The updated definition reflects what already had been observed in T-MSIS data: most states report a majority of eligibility records with English as the primary language code, suggesting they were not following the original variable definition but rather reporting what they gather on Medicaid applications, which offer English as an option for primary language. </p><p><a href=\"#footnote-ref-3\">\u2191</a></p></li>"}, {"number": 4, "content": "<li class=\"footnoteBody\" id=\"footnote-4\" value=\"3\"><p class=\"msword-footnote-text\"> For a list of valid values, see Codes for Representation of Names of Languages at <a aria-label=\"View ISO Codes for Representation of Names of Languages\" href=\"https://www.loc.gov/standards/iso639-2/php/code_list.php\">https://www.loc.gov/standards/iso639-2/php/code_list.php</a> . The ISO reviews its code sets every five years; the ISO 639-2 lifecycle can be viewed at <a aria-label=\"View ISO 639-2 Standard Life Cycle\" href=\"https://www.iso.org/standard/4767.html\">https://www.iso.org/standard/4767.html</a> . </p><p><a href=\"#footnote-ref-4\">\u2191</a></p></li>"}, {"number": 5, "content": "<li class=\"footnoteBody\" id=\"footnote-5\" value=\"4\"><p class=\"msword-footnote-text\"> In the internal version of the TAF data within the CMCS data environment, the primary language code is stored as \"Language (Other Than English) Code\" (OTHR_LANG_HOME_CD).\" </p><p><a href=\"#footnote-ref-5\">\u2191</a></p></li>"}, {"number": 6, "content": "<li class=\"footnoteBody\" id=\"footnote-6\" value=\"5\"><p class=\"msword-footnote-text\"> In the internal version of the TAF data within the CMCS data environment, the constructed primary language group code is stored as \"Constructed Primary Language (Other Than English) Group Code\" (PRMRY_LANG_FLAG).\" The categories in the constructed primary language group code come from the Social Security Administration Master Beneficiary Record variable for preferred written language. Although English is a valid value, it is widely accepted that users should assume English is the preferred language if the field is left blank. </p><p><a href=\"#footnote-ref-6\">\u2191</a></p></li>"}, {"number": 7, "content": "<li class=\"footnoteBody\" id=\"footnote-7\" value=\"6\"><p class=\"msword-footnote-text\"> The name of the T-MSIS English language proficiency code (and in turn, the TAF English language proficiency code) changed slightly in 2022 to clarify that states should capture the level of spoken English proficiency regardless of whether it is the individual\u2019s preferred spoken or written language. Previously, it was unclear whether the field should be populated for beneficiaries whose primary language was not English. The updated name reflects what states likely already gather on Medicaid applications. </p><p><a href=\"#footnote-ref-7\">\u2191</a></p></li>"}, {"number": 8, "content": "<li class=\"footnoteBody\" id=\"footnote-8\" value=\"7\"><p class=\"msword-footnote-text\"> We were not able to assess the validity of each language value available under the language code. Users interested in the level of specificity offered by the language code should adapt the methods used for this data quality assessment using the three-letter values for the languages of interest. </p><p><a href=\"#footnote-ref-8\">\u2191</a></p></li>"}]}, "methods": {"content": "<p class=\"msword-paragraph\"> For the primary language analysis, we examined the <a id=\"_Hlk50451021\"></a> constructed primary language group code (PRMRY_LANG_FLAG) on non-dummy enrollment records <sup class=\"msword-superscript\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-2\" id=\"footnote-ref-2\">[8]</a> </sup> </sup> in the TAF DE file. <sup class=\"msword-superscript\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-3\" id=\"footnote-ref-3\">[9]</a> </sup> </sup> We tabulated the proportion of records that fell into one of three categories: English, Spanish, and Other languages. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-4\" id=\"footnote-ref-4\">[10]</a> </sup> </sup> Following the Social Security Administration (SSA) and ACS convention, we categorized missing values as English; however, we calculated the percentage with null values separately for informational purposes.</p><p class=\"msword-paragraph\"> To construct the benchmark, we used the ACS five-year estimates <sup class=\"msword-superscript\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-5\" id=\"footnote-ref-5\">[11]</a> </sup> </sup> Public Use Microdata Sample (PUMS) <sup class=\"msword-superscript\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-6\" id=\"footnote-ref-6\">[12]</a> </sup> </sup> for a given year. The ACS data, which are collected annually from a nationally representative random sample of households, contain information on language spoken at home, English proficiency only for those respondents who do not speak English at home, and health insurance coverage. After pulling the ACS microdata from PUMS, we selected all individuals who reported having \"Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low incomes or a disability\" at the time of the survey. For individuals in that group, we calculated the percentage who were in the three aggregate language categories (English, Spanish, Other languages).</p><p class=\"msword-paragraph\"> The ACS asks respondents whether they speak a language other than English at home and, if so, what language they speak and how well they speak English. Users can assume that if the subsequent language and proficiency questions are not answered, the person speaks only English.</p><p class=\"msword-paragraph\"> ACS data are used by many stakeholders, including federal and state government agencies for policy and program-funding activities, and are considered a highly reliable source of demographic data. However, self-reporting of health insurance coverage for the ACS often results in an undercount compared to the number of Medicaid beneficiaries who appear in administrative data. Therefore, in this data quality assessment, we compare the percentage of Medicaid beneficiaries in each language category in TAF to the comparable distribution in the ACS, rather than comparing the count of individuals in each category.</p><p class=\"msword-paragraph\"> Table 1 shows the level of concern for the TAF primary language variable based on how well the percentage of beneficiaries in each of the three aggregate language categories aligned with the ACS. For language categories that accounted for more than 10 percent of a state&rsquo;s Medicaid population in the ACS, we deemed a \"substantive difference\" between TAF and ACS to be more than 10 percentage points. For language categories that accounted for more than 2 percent and less than or equal to 10 percent of a state&rsquo;s Medicaid population in the ACS, we considered a substantive difference between the data sources to exist if there were no TAF records in the given language category. We assessed each state on the number of language categories in which TAF differs substantively from the ACS (either a 10 percentage point difference or zero TAF records, depending on the language category proportion in the ACS). We considered states with a missing primary language value for all beneficiaries in TAF to be unusable for language analyses.</p><p class=\"msword-table-title\"> Table 1. Criteria for DQ assessment of the constructed primary language group code</p><table aria-label=\"Table 1. Criteria for DQ assessment of the constructed primary language group code\" class=\"dq-assessment-table\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Number of language categories (out of three) in which TAF differs substantively from ACS </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Percentage of beneficiaries with missing primary language in TAF </p> </th> <th class=\"msword-table-header-center dq-assessment-col\"> <p class=\"msword-table-header-center\"> DQ assessment </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> 0 </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> x &lt; 100 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level low\"> <p class=\"msword-table-text-centered\"> Low concern </p> </td> </tr> <tr> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> 1 </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> x &lt; 100 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level medium\"> <p class=\"msword-table-text-centered\"> Medium concern </p> </td> </tr> <tr> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> 2 </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> x &lt; 100 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level high\"> <p class=\"msword-table-text-centered\"> High concern </p> </td> </tr> <tr> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> 3 </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> x &lt; 100 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level unusable\"> <p class=\"msword-table-text-centered\"> Unusable </p> </td> </tr> <tr> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Any value </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> x = 100 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level unusable\"> <p class=\"msword-table-text-centered\"> Unusable </p> </td> </tr> </tbody></table><p class=\"msword-paragraph-continued\"> For the spoken English proficiency analysis, we examined the English language proficiency code (PRMRY_LANG_ENGLSH_PRFCNCY_CD) on non-dummy enrollment records in the TAF DE file. We limited the analysis to beneficiaries who indicated a non-English primary language. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-7\" id=\"footnote-ref-7\">[13]</a> </sup> </sup> We tabulated the proportion of these records that fell into each one of two aggregate proficiency categories (\"very well\" or \"well\" versus \"not well\" or \"no spoken proficiency\"), as well as the proportion with missing values. The assessment focuses on beneficiaries with limited English proficiency&mdash;those with proficiency categories \"not well\" or \"no spoken proficiency.\"</p><p class=\"msword-paragraph\"> We used two criteria to assess each state&rsquo;s spoken English proficiency data, both measured only among beneficiaries that reported a non-English primary language. First, we calculated the percentage of these beneficiaries with missing English proficiency data. Second, we assessed the extent to which the percentage of beneficiaries with limited English proficiency&mdash;that is, those in the categories \"not well\" or \"no spoken proficiency\"&mdash;aligns with the ACS benchmark data for the state (Table 2).</p><p class=\"msword-table-title\"> Table 2. Criteria for DQ assessment of English language proficiency code (assessed only among beneficiaries with a non-English primary language)</p><table aria-label=\"Table 2. Criteria for DQ assessment of English language proficiency code (assessed only among beneficiaries with a non-English primary language)\" class=\"dq-assessment-table\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Percentage of beneficiaries with missing English proficiency in TAF </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> <a id=\"_Hlk34046597\"></a> Percentage of beneficiaries with limited English proficiency in TAF differs substantively from ACS </p> </th> <th class=\"msword-table-header-center dq-assessment-col\"> <p class=\"msword-table-header-center\"> DQ assessment </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &le; 10 percent </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> No </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level low\"> <p class=\"msword-table-text-centered\"> Low concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &le; 10 percent </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Yes </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level medium\"> <p class=\"msword-table-text-centered\"> Medium concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 10 percent &lt; x &le; 20 percent </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> No </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level medium\"> <p class=\"msword-table-text-centered\"> Medium concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 10 percent &lt; x &le; 20 percent </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Yes </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level high\"> <p class=\"msword-table-text-centered\"> High concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 20 percent &lt; x &le; 50 percent </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> No </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level high\"> <p class=\"msword-table-text-centered\"> High concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 20 percent &lt; x &le; 50 percent </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Yes </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level unusable\"> <p class=\"msword-table-text-centered\"> Unusable </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &gt; 50 percent </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Any value </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level unusable\"> <p class=\"msword-table-text-centered\"> Unusable </p> </td> </tr> </tbody></table><ol> <li class=\"footnoteBody\" id=\"footnote-2\" value=\"8\"> <p class=\"msword-footnote-text\"> We excluded DE records representing beneficiary IDs that are present on claims but were not included in the eligibility records submitted by the state (those with MISG_ELGBLTY_DATA_IND = 1). </p> <p> <a href=\"#footnote-ref-2\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-3\" value=\"9\"> <p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources page</a> , and a crosswalk of variable names can be found in the guide \"Production of the TAF Research Identifiable Files.\" </p> <p> <a href=\"#footnote-ref-3\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-4\" value=\"10\"> <p class=\"msword-footnote-text\"> We chose only three groups (English, Spanish, and Other) for the assessment because they align with the HHS minimum recommendations. </p> <p> <a href=\"#footnote-ref-4\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-5\" value=\"11\"> <p class=\"msword-footnote-text\"> <a id=\"_Hlk47010181\"></a> <a id=\"_Hlk47010182\"></a> ACS five-year estimates are more reliable and complete than ACS one-year estimates and the Current Population Survey because they include smaller geographic areas and have a larger sample size. For more details, see <a aria-label=\"View American Community Survey Guidance for Data Users: When to Use 1-year or 5-year Estimates\" href=\"https://www.census.gov/programs-surveys/acs/guidance/estimates.html\">https://www.census.gov/programs-surveys/acs/guidance/estimates.html</a> and <a aria-label=\"View a Health Services Research article on The American Community Survey and Health Insurance Coverage Estimates\" href=\"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2677056/\">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2677056/</a> . </p> <p> <a href=\"#footnote-ref-5\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-6\" value=\"12\"> <p class=\"msword-footnote-text\"> See <a aria-label=\"Explore the American Community Survey data\" href=\"https://data.census.gov/mdat/#/\">https://data.census.gov/mdat/#/</a> . </p> <p> <a href=\"#footnote-ref-6\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-7\" value=\"13\"> <p class=\"msword-footnote-text\"> Although CMS guidance is to report English proficiency for all beneficiaries (even those whose primary language is English), most analytic users will be interested in the ability to speak English of beneficiaries whose primary language is not English. </p> <p> <a href=\"#footnote-ref-7\">&uarr;</a> </p> </li></ol>", "footnotes": [{"number": 2, "content": "<li class=\"footnoteBody\" id=\"footnote-2\" value=\"8\"><p class=\"msword-footnote-text\"> We excluded DE records representing beneficiary IDs that are present on claims but were not included in the eligibility records submitted by the state (those with MISG_ELGBLTY_DATA_IND = 1). </p><p><a href=\"#footnote-ref-2\">\u2191</a></p></li>"}, {"number": 3, "content": "<li class=\"footnoteBody\" id=\"footnote-3\" value=\"9\"><p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources page</a> , and a crosswalk of variable names can be found in the guide \"Production of the TAF Research Identifiable Files.\" </p><p><a href=\"#footnote-ref-3\">\u2191</a></p></li>"}, {"number": 4, "content": "<li class=\"footnoteBody\" id=\"footnote-4\" value=\"10\"><p class=\"msword-footnote-text\"> We chose only three groups (English, Spanish, and Other) for the assessment because they align with the HHS minimum recommendations. </p><p><a href=\"#footnote-ref-4\">\u2191</a></p></li>"}, {"number": 5, "content": "<li class=\"footnoteBody\" id=\"footnote-5\" value=\"11\"><p class=\"msword-footnote-text\"><a id=\"_Hlk47010181\"></a><a id=\"_Hlk47010182\"></a> ACS five-year estimates are more reliable and complete than ACS one-year estimates and the Current Population Survey because they include smaller geographic areas and have a larger sample size. For more details, see <a aria-label=\"View American Community Survey Guidance for Data Users: When to Use 1-year or 5-year Estimates\" href=\"https://www.census.gov/programs-surveys/acs/guidance/estimates.html\">https://www.census.gov/programs-surveys/acs/guidance/estimates.html</a> and <a aria-label=\"View a Health Services Research article on The American Community Survey and Health Insurance Coverage Estimates\" href=\"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2677056/\">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2677056/</a> . </p><p><a href=\"#footnote-ref-5\">\u2191</a></p></li>"}, {"number": 6, "content": "<li class=\"footnoteBody\" id=\"footnote-6\" value=\"12\"><p class=\"msword-footnote-text\"> See <a aria-label=\"Explore the American Community Survey data\" href=\"https://data.census.gov/mdat/#/\">https://data.census.gov/mdat/#/</a> . </p><p><a href=\"#footnote-ref-6\">\u2191</a></p></li>"}, {"number": 7, "content": "<li class=\"footnoteBody\" id=\"footnote-7\" value=\"13\"><p class=\"msword-footnote-text\"> Although CMS guidance is to report English proficiency for all beneficiaries (even those whose primary language is English), most analytic users will be interested in the ability to speak English of beneficiaries whose primary language is not English. </p><p><a href=\"#footnote-ref-7\">\u2191</a></p></li>"}]}, "summary": {"content": "<p>The TAF eligibility files include information on select demographic characteristics of beneficiaries enrolled in Medicaid or CHIP. This analysis examines the completeness and reliability of language information in the TAF. It also examines how well the TAF data on primary or preferred language and English language proficiency align with an external benchmark, the U.S. Census Bureau's American Community Survey.</p>", "footnotes": []}, "originalIssueBriefId": "4181", "relatedTopics": [{"measureId": 120, "measureName": "English Language Proficiency", "groupId": 3, "groupName": "Beneficiary Information", "order": 1}]}
120
{"measureId": 120, "measureName": "English Language Proficiency", "groupId": 3, "groupName": "Beneficiary Information", "pdfVersionLink": "downloads/background-and-methods/TAF-DQ-Eng-Lang-Prof.pdf", "background": {"content": "<p class=\"msword-paragraph\"> <a id=\"_Hlk30592933\"></a> The T-MSIS Analytic Files (TAF) are research-optimized data on beneficiaries enrolled in Medicaid and the Children&rsquo;s Health Insurance Program (CHIP). The Annual Demographic and Eligibility (DE) file contains information on beneficiary demographic characteristics, including primary or preferred language and English language proficiency. States often gather this information via applications for Medicaid and CHIP benefits. However, states may vary in whether and how they ask these questions because language information is not required for eligibility determination. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-2\" id=\"footnote-ref-2\">[1]</a> </sup> </sup> <a id=\"_Hlk101268128\"></a> Although the U.S. Department of Health and Human Services (HHS) recommends that states give at minimum two language options other than English ( <em> Spanish </em> or <em> Other language </em> ), some states give applicants a range of languages from which to choose.</p><p class=\"msword-paragraph\"> States use one data element to submit information on a beneficiary&rsquo;s language preference in T-MSIS: the primary language code, <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-3\" id=\"footnote-ref-3\">[2]</a> </sup> </sup> which uses a valid value set of approximately 500 three-letter categories from the International Organization for Standardization (ISO) codes for the representation of names of languages, Part 2 (ISO 639-2). <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-4\" id=\"footnote-ref-4\">[3]</a> </sup> </sup> When eligibility records are created in TAF, this source data element is used to create two TAF data elements: (1) the primary language code, <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-5\" id=\"footnote-ref-5\">[4]</a> </sup> </sup> which takes on all of the ISO 639-2 language codes as valid values; and (2) the constructed primary language group code, with 14 valid values. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-6\" id=\"footnote-ref-6\">[5]</a> </sup> </sup> States vary in whether they report the English ISO language code or leave the data element blank when a beneficiary&rsquo;s primary language is English.</p><p class=\"msword-paragraph\"> In addition, states use one data element to submit information on how well a beneficiary speaks English: the English language proficiency code, <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-7\" id=\"footnote-ref-7\">[6]</a> </sup> </sup> which uses a four-point scale (no spoken proficiency, does not speak well, speaks well, speaks very well).</p><p class=\"msword-paragraph\"> This analysis assesses the usability of the constructed primary language group code <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-8\" id=\"footnote-ref-8\">[7]</a> </sup> </sup> by measuring the extent to which certain language categories (English, Spanish, Other) align with an external benchmark, the American Community Survey (ACS). We also assess the usability of the English language proficiency code among beneficiaries with Spanish or Other primary language in TAF by measuring the extent to which certain English proficiency categories (\"not well\" or \"no spoken proficiency\") differ substantively from the ACS.</p><ol> <li class=\"footnoteBody\" id=\"footnote-2\" value=\"1\"> <p class=\"msword-footnote-text\"> More information about the collection of race, ethnicity, and language data in Medicaid Applications is available at <a aria-label=\"View Issue Brief: Collection of Race, Ethnicity, Language (REL) Data in Medicaid Applications\" href=\"https://www.shvs.org/wp-content/uploads/2021/05/SHVS-50-State-Review-EDITED.pdf\">https://www.shvs.org/wp-content/uploads/2021/05/SHVS-50-State-Review-EDITED.pdf</a> . </p> <p> <a href=\"#footnote-ref-2\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-3\" value=\"2\"> <p class=\"msword-footnote-text\"> The definition of the T-MSIS primary language code (and in turn, the TAF language code and constructed primary language group code) changed slightly in 2022 to represent \"the individual&rsquo;s preferred spoken or written language\" (which may or may not be English) rather than the individual&rsquo;s language \"other than English.\" The updated definition reflects what already had been observed in T-MSIS data: most states report a majority of eligibility records with English as the primary language code, suggesting they were not following the original variable definition but rather reporting what they gather on Medicaid applications, which offer English as an option for primary language. </p> <p> <a href=\"#footnote-ref-3\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-4\" value=\"3\"> <p class=\"msword-footnote-text\"> For a list of valid values, see Codes for Representation of Names of Languages at <a aria-label=\"View ISO Codes for Representation of Names of Languages\" href=\"https://www.loc.gov/standards/iso639-2/php/code_list.php\">https://www.loc.gov/standards/iso639-2/php/code_list.php</a> . The ISO reviews its code sets every five years; the ISO 639-2 lifecycle can be viewed at <a aria-label=\"View ISO 639-2 Standard Life Cycle\" href=\"https://www.iso.org/standard/4767.html\">https://www.iso.org/standard/4767.html</a> . </p> <p> <a href=\"#footnote-ref-4\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-5\" value=\"4\"> <p class=\"msword-footnote-text\"> In the internal version of the TAF data within the CMCS data environment, the primary language code is stored as \"Language (Other Than English) Code\" (OTHR_LANG_HOME_CD).\" </p> <p> <a href=\"#footnote-ref-5\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-6\" value=\"5\"> <p class=\"msword-footnote-text\"> In the internal version of the TAF data within the CMCS data environment, the constructed primary language group code is stored as \"Constructed Primary Language (Other Than English) Group Code\" (PRMRY_LANG_FLAG).\" The categories in the constructed primary language group code come from the Social Security Administration Master Beneficiary Record variable for preferred written language. Although English is a valid value, it is widely accepted that users should assume English is the preferred language if the field is left blank. </p> <p> <a href=\"#footnote-ref-6\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-7\" value=\"6\"> <p class=\"msword-footnote-text\"> The name of the T-MSIS English language proficiency code (and in turn, the TAF English language proficiency code) changed slightly in 2022 to clarify that states should capture the level of spoken English proficiency regardless of whether it is the individual&rsquo;s preferred spoken or written language. Previously, it was unclear whether the field should be populated for beneficiaries whose primary language was not English. The updated name reflects what states likely already gather on Medicaid applications. </p> <p> <a href=\"#footnote-ref-7\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-8\" value=\"7\"> <p class=\"msword-footnote-text\"> We were not able to assess the validity of each language value available under the language code. Users interested in the level of specificity offered by the language code should adapt the methods used for this data quality assessment using the three-letter values for the languages of interest. </p> <p> <a href=\"#footnote-ref-8\">&uarr;</a> </p> </li></ol>", "footnotes": [{"number": 2, "content": "<li class=\"footnoteBody\" id=\"footnote-2\" value=\"1\"><p class=\"msword-footnote-text\"> More information about the collection of race, ethnicity, and language data in Medicaid Applications is available at <a aria-label=\"View Issue Brief: Collection of Race, Ethnicity, Language (REL) Data in Medicaid Applications\" href=\"https://www.shvs.org/wp-content/uploads/2021/05/SHVS-50-State-Review-EDITED.pdf\">https://www.shvs.org/wp-content/uploads/2021/05/SHVS-50-State-Review-EDITED.pdf</a> . </p><p><a href=\"#footnote-ref-2\">\u2191</a></p></li>"}, {"number": 3, "content": "<li class=\"footnoteBody\" id=\"footnote-3\" value=\"2\"><p class=\"msword-footnote-text\"> The definition of the T-MSIS primary language code (and in turn, the TAF language code and constructed primary language group code) changed slightly in 2022 to represent \"the individual\u2019s preferred spoken or written language\" (which may or may not be English) rather than the individual\u2019s language \"other than English.\" The updated definition reflects what already had been observed in T-MSIS data: most states report a majority of eligibility records with English as the primary language code, suggesting they were not following the original variable definition but rather reporting what they gather on Medicaid applications, which offer English as an option for primary language. </p><p><a href=\"#footnote-ref-3\">\u2191</a></p></li>"}, {"number": 4, "content": "<li class=\"footnoteBody\" id=\"footnote-4\" value=\"3\"><p class=\"msword-footnote-text\"> For a list of valid values, see Codes for Representation of Names of Languages at <a aria-label=\"View ISO Codes for Representation of Names of Languages\" href=\"https://www.loc.gov/standards/iso639-2/php/code_list.php\">https://www.loc.gov/standards/iso639-2/php/code_list.php</a> . The ISO reviews its code sets every five years; the ISO 639-2 lifecycle can be viewed at <a aria-label=\"View ISO 639-2 Standard Life Cycle\" href=\"https://www.iso.org/standard/4767.html\">https://www.iso.org/standard/4767.html</a> . </p><p><a href=\"#footnote-ref-4\">\u2191</a></p></li>"}, {"number": 5, "content": "<li class=\"footnoteBody\" id=\"footnote-5\" value=\"4\"><p class=\"msword-footnote-text\"> In the internal version of the TAF data within the CMCS data environment, the primary language code is stored as \"Language (Other Than English) Code\" (OTHR_LANG_HOME_CD).\" </p><p><a href=\"#footnote-ref-5\">\u2191</a></p></li>"}, {"number": 6, "content": "<li class=\"footnoteBody\" id=\"footnote-6\" value=\"5\"><p class=\"msword-footnote-text\"> In the internal version of the TAF data within the CMCS data environment, the constructed primary language group code is stored as \"Constructed Primary Language (Other Than English) Group Code\" (PRMRY_LANG_FLAG).\" The categories in the constructed primary language group code come from the Social Security Administration Master Beneficiary Record variable for preferred written language. Although English is a valid value, it is widely accepted that users should assume English is the preferred language if the field is left blank. </p><p><a href=\"#footnote-ref-6\">\u2191</a></p></li>"}, {"number": 7, "content": "<li class=\"footnoteBody\" id=\"footnote-7\" value=\"6\"><p class=\"msword-footnote-text\"> The name of the T-MSIS English language proficiency code (and in turn, the TAF English language proficiency code) changed slightly in 2022 to clarify that states should capture the level of spoken English proficiency regardless of whether it is the individual\u2019s preferred spoken or written language. Previously, it was unclear whether the field should be populated for beneficiaries whose primary language was not English. The updated name reflects what states likely already gather on Medicaid applications. </p><p><a href=\"#footnote-ref-7\">\u2191</a></p></li>"}, {"number": 8, "content": "<li class=\"footnoteBody\" id=\"footnote-8\" value=\"7\"><p class=\"msword-footnote-text\"> We were not able to assess the validity of each language value available under the language code. Users interested in the level of specificity offered by the language code should adapt the methods used for this data quality assessment using the three-letter values for the languages of interest. </p><p><a href=\"#footnote-ref-8\">\u2191</a></p></li>"}]}, "methods": {"content": "<p class=\"msword-paragraph\"> For the primary language analysis, we examined the <a id=\"_Hlk50451021\"></a> constructed primary language group code (PRMRY_LANG_FLAG) on non-dummy enrollment records <sup class=\"msword-superscript\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-2\" id=\"footnote-ref-2\">[8]</a> </sup> </sup> in the TAF DE file. <sup class=\"msword-superscript\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-3\" id=\"footnote-ref-3\">[9]</a> </sup> </sup> We tabulated the proportion of records that fell into one of three categories: English, Spanish, and Other languages. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-4\" id=\"footnote-ref-4\">[10]</a> </sup> </sup> Following the Social Security Administration (SSA) and ACS convention, we categorized missing values as English; however, we calculated the percentage with null values separately for informational purposes.</p><p class=\"msword-paragraph\"> To construct the benchmark, we used the ACS five-year estimates <sup class=\"msword-superscript\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-5\" id=\"footnote-ref-5\">[11]</a> </sup> </sup> Public Use Microdata Sample (PUMS) <sup class=\"msword-superscript\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-6\" id=\"footnote-ref-6\">[12]</a> </sup> </sup> for a given year. The ACS data, which are collected annually from a nationally representative random sample of households, contain information on language spoken at home, English proficiency only for those respondents who do not speak English at home, and health insurance coverage. After pulling the ACS microdata from PUMS, we selected all individuals who reported having \"Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low incomes or a disability\" at the time of the survey. For individuals in that group, we calculated the percentage who were in the three aggregate language categories (English, Spanish, Other languages).</p><p class=\"msword-paragraph\"> The ACS asks respondents whether they speak a language other than English at home and, if so, what language they speak and how well they speak English. Users can assume that if the subsequent language and proficiency questions are not answered, the person speaks only English.</p><p class=\"msword-paragraph\"> ACS data are used by many stakeholders, including federal and state government agencies for policy and program-funding activities, and are considered a highly reliable source of demographic data. However, self-reporting of health insurance coverage for the ACS often results in an undercount compared to the number of Medicaid beneficiaries who appear in administrative data. Therefore, in this data quality assessment, we compare the percentage of Medicaid beneficiaries in each language category in TAF to the comparable distribution in the ACS, rather than comparing the count of individuals in each category.</p><p class=\"msword-paragraph\"> Table 1 shows the level of concern for the TAF primary language variable based on how well the percentage of beneficiaries in each of the three aggregate language categories aligned with the ACS. For language categories that accounted for more than 10 percent of a state&rsquo;s Medicaid population in the ACS, we deemed a \"substantive difference\" between TAF and ACS to be more than 10 percentage points. For language categories that accounted for more than 2 percent and less than or equal to 10 percent of a state&rsquo;s Medicaid population in the ACS, we considered a substantive difference between the data sources to exist if there were no TAF records in the given language category. We assessed each state on the number of language categories in which TAF differs substantively from the ACS (either a 10 percentage point difference or zero TAF records, depending on the language category proportion in the ACS). We considered states with a missing primary language value for all beneficiaries in TAF to be unusable for language analyses.</p><p class=\"msword-table-title\"> Table 1. Criteria for DQ assessment of the constructed primary language group code</p><table aria-label=\"Table 1. Criteria for DQ assessment of the constructed primary language group code\" class=\"dq-assessment-table\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Number of language categories (out of three) in which TAF differs substantively from ACS </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Percentage of beneficiaries with missing primary language in TAF </p> </th> <th class=\"msword-table-header-center dq-assessment-col\"> <p class=\"msword-table-header-center\"> DQ assessment </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> 0 </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> x &lt; 100 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level low\"> <p class=\"msword-table-text-centered\"> Low concern </p> </td> </tr> <tr> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> 1 </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> x &lt; 100 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level medium\"> <p class=\"msword-table-text-centered\"> Medium concern </p> </td> </tr> <tr> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> 2 </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> x &lt; 100 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level high\"> <p class=\"msword-table-text-centered\"> High concern </p> </td> </tr> <tr> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> 3 </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> x &lt; 100 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level unusable\"> <p class=\"msword-table-text-centered\"> Unusable </p> </td> </tr> <tr> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Any value </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> x = 100 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level unusable\"> <p class=\"msword-table-text-centered\"> Unusable </p> </td> </tr> </tbody></table><p class=\"msword-paragraph-continued\"> For the spoken English proficiency analysis, we examined the English language proficiency code (PRMRY_LANG_ENGLSH_PRFCNCY_CD) on non-dummy enrollment records in the TAF DE file. We limited the analysis to beneficiaries who indicated a non-English primary language. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-7\" id=\"footnote-ref-7\">[13]</a> </sup> </sup> We tabulated the proportion of these records that fell into each one of two aggregate proficiency categories (\"very well\" or \"well\" versus \"not well\" or \"no spoken proficiency\"), as well as the proportion with missing values. The assessment focuses on beneficiaries with limited English proficiency&mdash;those with proficiency categories \"not well\" or \"no spoken proficiency.\"</p><p class=\"msword-paragraph\"> We used two criteria to assess each state&rsquo;s spoken English proficiency data, both measured only among beneficiaries that reported a non-English primary language. First, we calculated the percentage of these beneficiaries with missing English proficiency data. Second, we assessed the extent to which the percentage of beneficiaries with limited English proficiency&mdash;that is, those in the categories \"not well\" or \"no spoken proficiency\"&mdash;aligns with the ACS benchmark data for the state (Table 2).</p><p class=\"msword-table-title\"> Table 2. Criteria for DQ assessment of English language proficiency code (assessed only among beneficiaries with a non-English primary language)</p><table aria-label=\"Table 2. Criteria for DQ assessment of English language proficiency code (assessed only among beneficiaries with a non-English primary language)\" class=\"dq-assessment-table\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Percentage of beneficiaries with missing English proficiency in TAF </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> <a id=\"_Hlk34046597\"></a> Percentage of beneficiaries with limited English proficiency in TAF differs substantively from ACS </p> </th> <th class=\"msword-table-header-center dq-assessment-col\"> <p class=\"msword-table-header-center\"> DQ assessment </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &le; 10 percent </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> No </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level low\"> <p class=\"msword-table-text-centered\"> Low concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &le; 10 percent </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Yes </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level medium\"> <p class=\"msword-table-text-centered\"> Medium concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 10 percent &lt; x &le; 20 percent </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> No </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level medium\"> <p class=\"msword-table-text-centered\"> Medium concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 10 percent &lt; x &le; 20 percent </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Yes </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level high\"> <p class=\"msword-table-text-centered\"> High concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 20 percent &lt; x &le; 50 percent </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> No </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level high\"> <p class=\"msword-table-text-centered\"> High concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 20 percent &lt; x &le; 50 percent </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Yes </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level unusable\"> <p class=\"msword-table-text-centered\"> Unusable </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &gt; 50 percent </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Any value </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level unusable\"> <p class=\"msword-table-text-centered\"> Unusable </p> </td> </tr> </tbody></table><ol> <li class=\"footnoteBody\" id=\"footnote-2\" value=\"8\"> <p class=\"msword-footnote-text\"> We excluded DE records representing beneficiary IDs that are present on claims but were not included in the eligibility records submitted by the state (those with MISG_ELGBLTY_DATA_IND = 1). </p> <p> <a href=\"#footnote-ref-2\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-3\" value=\"9\"> <p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources page</a> , and a crosswalk of variable names can be found in the guide \"Production of the TAF Research Identifiable Files.\" </p> <p> <a href=\"#footnote-ref-3\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-4\" value=\"10\"> <p class=\"msword-footnote-text\"> We chose only three groups (English, Spanish, and Other) for the assessment because they align with the HHS minimum recommendations. </p> <p> <a href=\"#footnote-ref-4\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-5\" value=\"11\"> <p class=\"msword-footnote-text\"> <a id=\"_Hlk47010181\"></a> <a id=\"_Hlk47010182\"></a> ACS five-year estimates are more reliable and complete than ACS one-year estimates and the Current Population Survey because they include smaller geographic areas and have a larger sample size. For more details, see <a aria-label=\"View American Community Survey Guidance for Data Users: When to Use 1-year or 5-year Estimates\" href=\"https://www.census.gov/programs-surveys/acs/guidance/estimates.html\">https://www.census.gov/programs-surveys/acs/guidance/estimates.html</a> and <a aria-label=\"View a Health Services Research article on The American Community Survey and Health Insurance Coverage Estimates\" href=\"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2677056/\">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2677056/</a> . </p> <p> <a href=\"#footnote-ref-5\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-6\" value=\"12\"> <p class=\"msword-footnote-text\"> See <a aria-label=\"Explore the American Community Survey data\" href=\"https://data.census.gov/mdat/#/\">https://data.census.gov/mdat/#/</a> . </p> <p> <a href=\"#footnote-ref-6\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-7\" value=\"13\"> <p class=\"msword-footnote-text\"> Although CMS guidance is to report English proficiency for all beneficiaries (even those whose primary language is English), most analytic users will be interested in the ability to speak English of beneficiaries whose primary language is not English. </p> <p> <a href=\"#footnote-ref-7\">&uarr;</a> </p> </li></ol>", "footnotes": [{"number": 2, "content": "<li class=\"footnoteBody\" id=\"footnote-2\" value=\"8\"><p class=\"msword-footnote-text\"> We excluded DE records representing beneficiary IDs that are present on claims but were not included in the eligibility records submitted by the state (those with MISG_ELGBLTY_DATA_IND = 1). </p><p><a href=\"#footnote-ref-2\">\u2191</a></p></li>"}, {"number": 3, "content": "<li class=\"footnoteBody\" id=\"footnote-3\" value=\"9\"><p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources page</a> , and a crosswalk of variable names can be found in the guide \"Production of the TAF Research Identifiable Files.\" </p><p><a href=\"#footnote-ref-3\">\u2191</a></p></li>"}, {"number": 4, "content": "<li class=\"footnoteBody\" id=\"footnote-4\" value=\"10\"><p class=\"msword-footnote-text\"> We chose only three groups (English, Spanish, and Other) for the assessment because they align with the HHS minimum recommendations. </p><p><a href=\"#footnote-ref-4\">\u2191</a></p></li>"}, {"number": 5, "content": "<li class=\"footnoteBody\" id=\"footnote-5\" value=\"11\"><p class=\"msword-footnote-text\"><a id=\"_Hlk47010181\"></a><a id=\"_Hlk47010182\"></a> ACS five-year estimates are more reliable and complete than ACS one-year estimates and the Current Population Survey because they include smaller geographic areas and have a larger sample size. For more details, see <a aria-label=\"View American Community Survey Guidance for Data Users: When to Use 1-year or 5-year Estimates\" href=\"https://www.census.gov/programs-surveys/acs/guidance/estimates.html\">https://www.census.gov/programs-surveys/acs/guidance/estimates.html</a> and <a aria-label=\"View a Health Services Research article on The American Community Survey and Health Insurance Coverage Estimates\" href=\"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2677056/\">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2677056/</a> . </p><p><a href=\"#footnote-ref-5\">\u2191</a></p></li>"}, {"number": 6, "content": "<li class=\"footnoteBody\" id=\"footnote-6\" value=\"12\"><p class=\"msword-footnote-text\"> See <a aria-label=\"Explore the American Community Survey data\" href=\"https://data.census.gov/mdat/#/\">https://data.census.gov/mdat/#/</a> . </p><p><a href=\"#footnote-ref-6\">\u2191</a></p></li>"}, {"number": 7, "content": "<li class=\"footnoteBody\" id=\"footnote-7\" value=\"13\"><p class=\"msword-footnote-text\"> Although CMS guidance is to report English proficiency for all beneficiaries (even those whose primary language is English), most analytic users will be interested in the ability to speak English of beneficiaries whose primary language is not English. </p><p><a href=\"#footnote-ref-7\">\u2191</a></p></li>"}]}, "summary": {"content": "<p>The TAF eligibility files include information on select demographic characteristics of beneficiaries enrolled in Medicaid or CHIP. This analysis examines the completeness and reliability of language information in the TAF. It also examines how well the TAF data on primary or preferred language and English language proficiency align with an external benchmark, the U.S. Census Bureau's American Community Survey.</p>", "footnotes": []}, "originalIssueBriefId": "4181", "relatedTopics": [{"measureId": 119, "measureName": "Primary Language", "groupId": 3, "groupName": "Beneficiary Information", "order": 0}]}
121
{"measureId": 121, "measureName": "Availability of CMC Plan Encounter Data", "groupId": 4, "groupName": "Claim Files Completeness", "pdfVersionLink": "downloads/background-and-methods/TAF-DQ-CMC-Plan-Encounters-All.pdf", "background": {"content": "<p class=\"msword-paragraph\"> In 2020, 72 percent of Medicaid beneficiaries received the majority of their care through comprehensive managed care (CMC) plans. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-2\" id=\"footnote-ref-2\">[1]</a> </sup> </sup> States are required to report the services provided to beneficiaries through managed care plans in their monthly T-MSIS claims records. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-3\" id=\"footnote-ref-3\">[2]</a> </sup> </sup> CMS strengthened the requirement to report complete encounter data in 2018. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-4\" id=\"footnote-ref-4\">[3]</a> </sup> </sup> Complete reporting of CMC encounter data ensures that TAF users can accurately identify all services received by Medicaid and CHIP beneficiaries and their diagnosed health conditions, regardless of whether those services were delivered through managed care or the fee-for-service system.</p><p class=\"msword-paragraph\"> Historically, some states have under-reported encounter records due to challenges with collecting information from CMC plans, as data reporting requirements must be written into each contract between the State and CMC plan. As states have continued to renegotiate CMC contracts in the time after the strengthened 2018 guidance on encounter data reporting, the volume and quality of encounter records should improve. Where CMC data are un- or under-reported, TAF users will underestimate health care utilization and the prevalence of medical conditions in beneficiaries who are enrolled in managed care. Additionally, qualify of care and access to care measures are likely to be unreliable in states with missing encounter data for some or all plans.</p><p class=\"msword-paragraph\"> This data quality assessment examines the number of comprehensive managed care plans for which the state is reporting enrollment but not reporting any encounter data.</p><ol> <li class=\"footnoteBody\" id=\"footnote-2\" value=\"1\"> <p class=\"msword-footnote-text\"> Centers for Medicare &amp; Medicaid Services. &ldquo;Medicaid Managed Care Enrollment and Program Characteristics, 2020.&rdquo; Spring 2022. Available at <a aria-label=\"View the Medicaid Managed Care Enrollment Report\" href=\"https://www.medicaid.gov/medicaid/managed-care/enrollment-report/index.html\">https://www.medicaid.gov/medicaid/managed-care/enrollment-report/index.html</a> Accessed August 11, 2022. </p> <p> <a href=\"#footnote-ref-2\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-3\" value=\"2\"> <p class=\"msword-footnote-text\"> Subpart J: Conditions for Federal Financial Participation (FFP). Enrollee encounter data. 42 CFR &sect;438.818 (May 6, 2016). Available at <a aria-label=\"View the Code of Federal Regulations Title 42 Subpart J Conditions for Federal Financial Participation 438.818 Enrollee Encounter Data\" href=\"https://www.govinfo.gov/content/pkg/CFR-2018-title42-vol4/xml/CFR-2018-title42-vol4-part438.xml#seqnum438.818\">https://www.govinfo.gov/content/pkg/CFR-2018-title42-vol4/xml/CFR-2018-title42-vol4-part438.xml#seqnum438.818</a> . Accessed May 29, 2020. </p> <p> <a href=\"#footnote-ref-3\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-4\" value=\"3\"> <p class=\"msword-footnote-text\"> Centers for Medicare &amp; Medicaid Services. \"State Health Official Letter #18-008: Transformed-Medicaid Statistical Information System (T-MSIS).\" August 10, 2018. </p> <p> <a href=\"#footnote-ref-4\">&uarr;</a> </p> </li></ol>", "footnotes": [{"number": 2, "content": "<li class=\"footnoteBody\" id=\"footnote-2\" value=\"1\"><p class=\"msword-footnote-text\"> Centers for Medicare &amp; Medicaid Services. \u201cMedicaid Managed Care Enrollment and Program Characteristics, 2020.\u201d Spring 2022. Available at <a aria-label=\"View the Medicaid Managed Care Enrollment Report\" href=\"https://www.medicaid.gov/medicaid/managed-care/enrollment-report/index.html\">https://www.medicaid.gov/medicaid/managed-care/enrollment-report/index.html</a> Accessed August 11, 2022. </p><p><a href=\"#footnote-ref-2\">\u2191</a></p></li>"}, {"number": 3, "content": "<li class=\"footnoteBody\" id=\"footnote-3\" value=\"2\"><p class=\"msword-footnote-text\"> Subpart J: Conditions for Federal Financial Participation (FFP). Enrollee encounter data. 42 CFR \u00a7438.818 (May 6, 2016). Available at <a aria-label=\"View the Code of Federal Regulations Title 42 Subpart J Conditions for Federal Financial Participation 438.818 Enrollee Encounter Data\" href=\"https://www.govinfo.gov/content/pkg/CFR-2018-title42-vol4/xml/CFR-2018-title42-vol4-part438.xml#seqnum438.818\">https://www.govinfo.gov/content/pkg/CFR-2018-title42-vol4/xml/CFR-2018-title42-vol4-part438.xml#seqnum438.818</a> . Accessed May 29, 2020. </p><p><a href=\"#footnote-ref-3\">\u2191</a></p></li>"}, {"number": 4, "content": "<li class=\"footnoteBody\" id=\"footnote-4\" value=\"3\"><p class=\"msword-footnote-text\"> Centers for Medicare &amp; Medicaid Services. \"State Health Official Letter #18-008: Transformed-Medicaid Statistical Information System (T-MSIS).\" August 10, 2018. </p><p><a href=\"#footnote-ref-4\">\u2191</a></p></li>"}]}, "methods": {"content": "<p class=\"msword-paragraph\"> Using the TAF, <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-2\" id=\"footnote-ref-2\">[4]</a> </sup> </sup> we tabulated the number of CMC plans that had Medicaid or CHIP beneficiaries enrolled in the calendar year but did not have any encounters <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-3\" id=\"footnote-ref-3\">[5]</a> </sup> </sup> in the inpatient (IP) or other services (OT) claims files that could be linked to the plan. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-4\" id=\"footnote-ref-4\">[6]</a> </sup> </sup> This pattern suggests that specific CMC plans are entirely missing encounter records.</p><p class=\"msword-paragraph\"> The analysis included enrollment and managed care encounter records for all CMC plans serving Medicaid and CHIP beneficiaries. We did not analyze states with no CMC program in operation during the year, as captured in the Medicaid Managed Care Enrollment and Program Characteristics (MMCEPC) report. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-5\" id=\"footnote-ref-5\">[7]</a> </sup> </sup> For Illinois, we restricted our analysis to the original version of the claim, and we excluded all subsequent adjustment records in the state&rsquo;s TAF data. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-6\" id=\"footnote-ref-6\">[8]</a> </sup> </sup></p><p class=\"msword-paragraph\"> To assess potential issues with the completeness or quality of the CMC encounter data in each state, we calculated: (1) total number of CMC plans, (2) total number of CMC-enrolled months, and (3) number of CMC plans with no IP or OT encounters. The first two measures allow us to identify whether there are any CMCs in the state and whether there is any enrollment in CMC plans and are provided as contextual information for the assessment.</p><p class=\"msword-paragraph\"> To calculate the number of CMC plans in each state with enrollment during the year, we identified the number of unique managed care plan ID (MC_PLAN_ID) values with a managed care plan type code (MC_PLAN_TYPE_CD) of &lsquo;01&rsquo; or &lsquo;04&rsquo; in the Annual Demographic &amp; Eligibility (ADE) file. We then tabulated the number of CMC plans that had beneficiaries enrolled in the calendar year but did not have any encounters in either the IP or OT claims file that could be linked to the plan. Encounter records for a particular plan were identified as those with a claim type code of &lsquo;3&rsquo; or &lsquo;C&rsquo; and a matching plan ID present on the header record. We did not require a header record to link to an enrollment record that was coded as participating in the CMC plan to be counted in the measure. However, we did not a count a header record as representing encounter data from a particular plan if it had a missing beneficiary identifier or beneficiary identifier with an invalid format (values that start with &ldquo;&amp;&rdquo;), because these records may represent capitation payments or other lump-sum payments being made to the plan rather than encounter records.</p><p class=\"msword-paragraph\"> To identify states with incomplete managed care encounter reporting, we used the criteria presented in Table 1. States were only assessed as low concern if they had encounter data present for all CMC plans. More information on whether the encounter data were correctly formatted and whether the volume of encounter data was as expected given the size of the enrolled population can be found in other topics in <em> DQ Atlas </em> . <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-7\" id=\"footnote-ref-7\">[9]</a> </sup> </sup></p><p class=\"msword-table-title\"> Table 1. Criteria for DQ assessment of the availability of encounter data for CMC plans</p><table aria-label=\"Table 1. Criteria for DQ assessment of the availability of encounter data for CMC plans \" class=\"dq-assessment-table\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Number of CMC plans with no encounter records </p> </th> <th class=\"msword-table-header-center dq-assessment-col\"> <p class=\"msword-table-header-center\"> DQ assessment </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> None </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level low\"> <p class=\"msword-table-text-centered\"> Low concern </p> </td> </tr> <tr> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> At least one but not more than half of CMC plans in the state </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level medium\"> <p class=\"msword-table-text-centered\"> Medium concern </p> </td> </tr> <tr> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> More than half but not all CMC plans in the state </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level high\"> <p class=\"msword-table-text-centered\"> High concern </p> </td> </tr> <tr> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> All CMC plans in the state </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level unusable\"> <p class=\"msword-table-text-centered\"> Unusable </p> </td> </tr> </tbody></table><ol> <li class=\"footnoteBody\" id=\"footnote-2\" value=\"4\"> <p class=\"msword-footnote-text\"> <a id=\"_Hlk37699725\"></a> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\"><em>DQ Atlas Resources page</em></a> , and a crosswalk of variable names can be found in the guide &ldquo;Production of the TAF Research Identifiable Files.&rdquo; </p> <p> <a href=\"#footnote-ref-2\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-3\" value=\"5\"> <p class=\"msword-footnote-text\"> We identified managed care encounters by using claim type code (CLM_TYPE_CD) values of 3 and C. We limited the analysis to encounters with a managed care plan ID (MC_PLAN_ID) that linked to a managed care plan type code (MC_PLAN_TYPE_CD) of 01 (comprehensive managed care) or 04 (Health Insuring Organization). </p> <p> <a href=\"#footnote-ref-3\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-4\" value=\"6\"> <p class=\"msword-footnote-text\"> States have the option to carve institutional long-term care services and prescription drugs out of their comprehensive managed care plan benefit packages, so the absence of encounter data in the LT or RX files does not necessarily indicate missing service use information. However, all comprehensive managed care plans are required to cover inpatient services and select outpatient services, and so IP and OT encounters are expected to be present in TAF for every comprehensive managed care plan. </p> <p> <a href=\"#footnote-ref-4\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-5\" value=\"7\"> <p class=\"msword-footnote-text\"> States with no CMC program include those with zero enrollment in CMC plans, as well as those where less than one percent of the Medicaid program is enrolled in a CMC. </p> <p> <a href=\"#footnote-ref-5\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-6\" value=\"8\"> <p class=\"msword-footnote-text\"> Because of limitations in its claims processing system, Illinois captures adjustments to original claims as incremental credits or debits rather than voiding the original claim and submitting a replacement record with the new payment amount. As a result, the version of a record with the latest adjudication date may not represent the final action claim as it does in all other states. To ensure the TAF correctly captures all expenditures reported by Illinois into T-MSIS, all service use records are included in the IP, OT, LT, and RX files. This means that in some cases, the TAF will include multiple versions of a single claim for Illinois, so including all records in an analysis will overcount service utilization. To ensure that utilization counts are correct, we restricted our analysis to the original claim from each claim family by selecting only records where ADJSTMT_IND = 0 and ADJSTMT_CLM_NUM = null. For more information, see the guide, &ldquo;How to Use Illinois Claims Data,&rdquo; on ResDAC.org. </p> <p> <a href=\"#footnote-ref-6\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-7\" value=\"9\"> <p class=\"msword-footnote-text\"> See the DQ Atlas single-topic displays for the following topics: <a aria-label=\"View DQ Atlas single topic display for CMC Plan Encounters - IP\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g4m56\">CMC Plan Encounters &ndash; IP</a> , <a aria-label=\"View DQ Atlas single topic display for CMC Plan Encounters - LT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g4m57\">CMC Plan Encounters &ndash; LT</a> , <a aria-label=\"View DQ Atlas single topic display for CMC Plan Encounters - OT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g4m58\">CMC Plan Encounters &ndash; OT</a> , and <a aria-label=\"View DQ Atlas single topic display for CMC Plan Encounters - RX\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g4m59\">CMC Plan Encounters &ndash; RX</a> . </p> <p> <a href=\"#footnote-ref-7\">&uarr;</a> </p> </li></ol>", "footnotes": [{"number": 2, "content": "<li class=\"footnoteBody\" id=\"footnote-2\" value=\"4\"><p class=\"msword-footnote-text\"><a id=\"_Hlk37699725\"></a> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\"><em>DQ Atlas Resources page</em></a> , and a crosswalk of variable names can be found in the guide \u201cProduction of the TAF Research Identifiable Files.\u201d </p><p><a href=\"#footnote-ref-2\">\u2191</a></p></li>"}, {"number": 3, "content": "<li class=\"footnoteBody\" id=\"footnote-3\" value=\"5\"><p class=\"msword-footnote-text\"> We identified managed care encounters by using claim type code (CLM_TYPE_CD) values of 3 and C. We limited the analysis to encounters with a managed care plan ID (MC_PLAN_ID) that linked to a managed care plan type code (MC_PLAN_TYPE_CD) of 01 (comprehensive managed care) or 04 (Health Insuring Organization). </p><p><a href=\"#footnote-ref-3\">\u2191</a></p></li>"}, {"number": 4, "content": "<li class=\"footnoteBody\" id=\"footnote-4\" value=\"6\"><p class=\"msword-footnote-text\"> States have the option to carve institutional long-term care services and prescription drugs out of their comprehensive managed care plan benefit packages, so the absence of encounter data in the LT or RX files does not necessarily indicate missing service use information. However, all comprehensive managed care plans are required to cover inpatient services and select outpatient services, and so IP and OT encounters are expected to be present in TAF for every comprehensive managed care plan. </p><p><a href=\"#footnote-ref-4\">\u2191</a></p></li>"}, {"number": 5, "content": "<li class=\"footnoteBody\" id=\"footnote-5\" value=\"7\"><p class=\"msword-footnote-text\"> States with no CMC program include those with zero enrollment in CMC plans, as well as those where less than one percent of the Medicaid program is enrolled in a CMC. </p><p><a href=\"#footnote-ref-5\">\u2191</a></p></li>"}, {"number": 6, "content": "<li class=\"footnoteBody\" id=\"footnote-6\" value=\"8\"><p class=\"msword-footnote-text\"> Because of limitations in its claims processing system, Illinois captures adjustments to original claims as incremental credits or debits rather than voiding the original claim and submitting a replacement record with the new payment amount. As a result, the version of a record with the latest adjudication date may not represent the final action claim as it does in all other states. To ensure the TAF correctly captures all expenditures reported by Illinois into T-MSIS, all service use records are included in the IP, OT, LT, and RX files. This means that in some cases, the TAF will include multiple versions of a single claim for Illinois, so including all records in an analysis will overcount service utilization. To ensure that utilization counts are correct, we restricted our analysis to the original claim from each claim family by selecting only records where ADJSTMT_IND = 0 and ADJSTMT_CLM_NUM = null. For more information, see the guide, \u201cHow to Use Illinois Claims Data,\u201d on ResDAC.org. </p><p><a href=\"#footnote-ref-6\">\u2191</a></p></li>"}, {"number": 7, "content": "<li class=\"footnoteBody\" id=\"footnote-7\" value=\"9\"><p class=\"msword-footnote-text\"> See the DQ Atlas single-topic displays for the following topics: <a aria-label=\"View DQ Atlas single topic display for CMC Plan Encounters - IP\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g4m56\">CMC Plan Encounters \u2013 IP</a> , <a aria-label=\"View DQ Atlas single topic display for CMC Plan Encounters - LT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g4m57\">CMC Plan Encounters \u2013 LT</a> , <a aria-label=\"View DQ Atlas single topic display for CMC Plan Encounters - OT\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g4m58\">CMC Plan Encounters \u2013 OT</a> , and <a aria-label=\"View DQ Atlas single topic display for CMC Plan Encounters - RX\" class=\"bgm-relative-link\" href=\"landing/topics/single/map?topic=g4m59\">CMC Plan Encounters \u2013 RX</a> . </p><p><a href=\"#footnote-ref-7\">\u2191</a></p></li>"}]}, "summary": {"content": "<p>States are required to report into T-MSIS the encounter records that reflect services provided to Medicaid and CHIP beneficiaries by managed care organizations. In states with managed care programs, the inclusion of encounter data in the T-MSIS submissions is critical for understanding the full picture of beneficiary service use and health status. This assessment shows which states are reporting encounter data for all comprehensive managed care plans that enrolled any Medicaid or CHIP beneficiaries during the year.</p>", "footnotes": []}, "originalIssueBriefId": "5251", "relatedTopics": []}
122
{"measureId": 122, "measureName": "SSI Participation", "groupId": 1, "groupName": "Enrollment Benchmarking", "pdfVersionLink": "downloads/background-and-methods/TAF-DQ-SSI-Participation.pdf", "background": {"content": "<p class=\"msword-paragraph\"> Most individuals who qualify for Medicaid coverage do so through one of the major eligibility groups, each of which have different requirements: children, pregnant women, low-income adults, <a id=\"_Hlk119408271\"></a> older adults (those age 65 and older), and adults who have a disabling condition. For instance, individuals covered under the Supplemental Security Income (SSI) program often qualify for Medicaid because they have limited financial means and a long-lasting disabling condition; SSI receipt is one of the primary pathways for individuals with disabilities to qualify for Medicaid. People with disabilities who are not receiving SSI may still enroll in Medicaid via other eligibility groups, such as the working disabled or disabled adult children groups (which are considered disability pathways) or the adult expansion group (which is not considered a disability pathway).</p><p class=\"msword-paragraph\"> The SSI program provides financial support to individuals with long-lasting disabilities (including blindness) who have limited work history, income, and assets. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-2\" id=\"footnote-ref-2\">[1]</a> </sup> </sup> To qualify as having a disability or blindness, an individual must have a chronic physical or mental impairment that prevents them from doing any substantial gainful activity (if age 18 or older) or results in marked and severe functional limitations (if less than age 18). Social Security Administration (SSA) field offices manage SSI applications and verify non-medical eligibility information (such as age and employment) and state Disability Determination Services offices review the medical evidence to determine whether the person has a disability or is blind under the law. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-3\" id=\"footnote-ref-3\">[2]</a> </sup> </sup> On average, it takes three to five months to receive an initial decision on an SSI application; it can take substantially longer if an individual goes through the appeals process, which is common. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-4\" id=\"footnote-ref-4\">[3]</a> </sup> </sup> <sup> , </sup> <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-5\" id=\"footnote-ref-5\">[4]</a> </sup> </sup> Once an individual is enrolled in SSI, they must report earnings or other changes (like increased assets or incarceration) that might disqualify them for SSI benefits as often as on a monthly basis. Additionally, SSA periodically conducts \"continuing disability reviews\" to confirm that a beneficiary&rsquo;s disability has not sufficiently improved to make them ineligible for benefits. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-6\" id=\"footnote-ref-6\">[5]</a> </sup> </sup></p><p class=\"msword-paragraph\"> Federal law requires states to provide Medicaid coverage to most individuals with disabilities who are receiving SSI payments. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-7\" id=\"footnote-ref-7\">[6]</a> </sup> </sup> Most states have a 1634 agreement with SSA, under which SSA makes Medicaid eligibility decisions in conjunction with SSI determinations (Table 1). In these states, SSI recipients are automatically conferred Medicaid coverage. Other states, called \"SSI criteria states,\" offer Medicaid to all SSI recipients, but require a separate application for each program. Finally, a few states elect an option provided in section 209(b) of the Social Security Act Amendments of 1972 <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-8\" id=\"footnote-ref-8\">[7]</a> </sup> </sup> which enables them to impose more stringent criteria for Medicaid eligibility than for SSI eligibility; these states are known as \"209(b) states.\" Although federal law prohibits 209(b) states from using more restrictive standards for Medicaid eligibility than those in effect on January 1, 1972, some SSI recipients may not be eligible for Medicaid coverage in those states.</p><p class=\"msword-table-title\"> Table 1. State policy options to determine Medicaid eligibility for SSI recipients</p><table aria-label=\"Table 1. State policy options to determine Medicaid eligibility for SSI recipients\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Policy </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Description </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Number of states </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 1634 agreement </p> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> SSA makes Medicaid eligibility decisions about persons receiving SSI payments and federally-administered state supplemental payments for them. </li> <li class=\"msword-table-list-bullet\"> Beneficiaries are granted Medicaid eligibility at the same time as SSI eligibility, and do not need to fill out a separate Medicaid application. </li> <li class=\"msword-table-list-bullet\"> SSA conducts redeterminations on behalf of the state Medicaid program, and the SSI redetermination is also a redetermination of Medicaid eligibility. </li> </ul> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> 35 </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> SSI criteria </p> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> States use the same eligibility criteria for Medicaid as SSA makes for SSI, but states make their own Medicaid eligibility determinations for SSI recipients. </li> <li class=\"msword-table-list-bullet\"> Individuals need to fill out a separate Medicaid application. </li> <li class=\"msword-table-list-bullet\"> The state Medicaid program renews Medicaid eligibility based on the findings from SSA&rsquo;s SSI redeterminations. </li> </ul> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> 7 </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 209(b) </p> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> State uses more restrictive criteria to determine Medicaid eligibility. </li> <li class=\"msword-table-list-bullet\"> The state Medicaid program conducts its own Medicaid eligibility determinations and redeterminations. </li> </ul> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> 9 </p> </td> </tr> </tbody></table><p class=\"msword-table-footnote\"> Sources: <a aria-label=\"View Social Security Administration Program Operations Manual System (POMS) SI 01715.010 - Medicaid and the Supplemental Security Income (SSI) Program\" href=\"https://secure.ssa.gov/poms.nsf/lnx/0501715010\">https://secure.ssa.gov/poms.nsf/lnx/0501715010</a> and <a aria-label='View Report from the U.S. Government Accountability Office (GAO): \"Medicaid: Information on the Use of Electronic Asset Verification to Determine Eligibility for Selected Beneficiaries\"' href=\"https://www.gao.gov/assets/gao-21-473r.pdf\">https://www.gao.gov/assets/gao-21-473r.pdf</a></p><p class=\"msword-paragraph\"> The eligibility group code in the T-MSIS Analytic Files (TAF), the research-ready version of T-MSIS, can be used to identify the basis on which an individual was deemed eligible for Medicaid or CHIP. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-9\" id=\"footnote-ref-9\">[8]</a> </sup> </sup> <sup> , </sup> <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-10\" id=\"footnote-ref-10\">[9]</a> </sup> </sup> Thirty-four of the eligibility group codes can be used to identify beneficiaries who qualified on the basis of disability, although several of these codes are also used to indicate beneficiaries qualified on the basis of age (Table 2). Restricting to beneficiaries under age 65 for the eligibility groups that include both disabled and aged beneficiaries enables TAF users to restrict their analysis to those who qualify for Medicaid on the basis of disability.</p><p class=\"msword-paragraph\"> Among the 34 eligibility group codes related to disability pathways for Medicaid eligibility, three codes appear to only include SSI recipients: 11, 12, and 13. These three codes account for more than half of all beneficiaries who qualify on the basis of disability. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-11\" id=\"footnote-ref-11\">[10]</a> </sup> </sup> Other eligibility group codes related to disability may include some SSI recipients but also include many non-recipients, such as Qualified Medicare Beneficiaries <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-12\" id=\"footnote-ref-12\">[11]</a> </sup> </sup> (code 23) and Optional State Supplement Recipients <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-13\" id=\"footnote-ref-13\">[12]</a> </sup> </sup> (codes 40 and 41).</p><p class=\"msword-table-title\"> Table 2. Eligibility group codes associated with disability pathways for Medicaid and CHIP eligibility</p><table aria-label=\"Table 2. Eligibility group codes associated with disability pathways for Medicaid and CHIP eligibility\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Eligibility Group Code </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Age requirement </p> </th> </tr> </thead> <tbody> <tr> <td> <p class=\"msword-table-text-left\"> 11: Individuals Receiving SSI <sup> a </sup> </p> <p class=\"msword-table-text-left\"> 12: Aged, Blind and Disabled Individuals in 209(b) States <sup> a </sup> </p> <p class=\"msword-table-text-left\"> 13: Individuals Receiving Mandatory State Supplements <sup> a </sup> </p> <p class=\"msword-table-text-left\"> 15: Institutionalized Individuals Continuously Eligible Since 1973 <sup> a </sup> </p> <p class=\"msword-table-text-left\"> 16: Blind or Disabled Individuals Eligible in 1973 <sup> a </sup> </p> <p class=\"msword-table-text-left\"> 17: Individuals Who Lost Eligibility for SSI/SSP Due to an Increase in OASDI Benefits in 1972 <sup> a </sup> </p> <p class=\"msword-table-text-left\"> 18: Individuals Who Would be Eligible for SSI/SSP but for OASDI COLA increases since April, 1977 <sup> a </sup> </p> <p class=\"msword-table-text-left\"> 19: Disabled Widows and Widowers Ineligible for SSI due to Increase in OASDI <sup> a </sup> </p> <p class=\"msword-table-text-left\"> 20: Disabled Widows and Widowers Ineligible for SSI due to Early Receipt of Social Security <sup> a </sup> </p> <p class=\"msword-table-text-left\"> 22: Disabled Adult Children <sup> a </sup> </p> <p class=\"msword-table-text-left\"> 23: Qualified Medicare Beneficiaries <sup> a </sup> </p> <p class=\"msword-table-text-left\"> 25: Specified Low Income Medicare Beneficiaries <sup> a </sup> </p> <p class=\"msword-table-text-left\"> 26: Qualifying Individuals <sup> a </sup> </p> <p class=\"msword-table-text-left\"> 37: Aged, Blind or Disabled Individuals Eligible for but Not Receiving Cash Assistance </p> <p class=\"msword-table-text-left\"> 38: Individuals Eligible for Cash Assistance except for Institutionalization </p> <p class=\"msword-table-text-left\"> 39: Individuals Receiving Home and Community Based Services under Institutional Rules </p> <p class=\"msword-table-text-left\"> 40: Optional State Supplement Recipients - 1634 States, and SSI Criteria States with 1616 Agreements </p> <p class=\"msword-table-text-left\"> 41: Optional State Supplement Recipients - 209(b) States, and SSI Criteria States without 1616 Agreements </p> <p class=\"msword-table-text-left\"> 42: Institutionalized Individuals Eligible under a Special Income Level </p> <p class=\"msword-table-text-left\"> 43: Individuals participating in a PACE Program under Institutional Rules </p> <p class=\"msword-table-text-left\"> 44: Individuals Receiving Hospice Care </p> <p class=\"msword-table-text-left\"> 46: Poverty Level Aged or Disabled </p> <p class=\"msword-table-text-left\"> 51: Individuals Eligible for Home and Community-Based Services </p> <p class=\"msword-table-text-left\"> 52: Individuals Eligible for Home and Community-Based Services &ndash; Special Income Level </p> <p class=\"msword-table-text-left\"> 59: Medically Needy Aged, Blind or Disabled <sup> b </sup> </p> <p class=\"msword-table-text-left\"> 60: Medically Needy Blind or Disabled Individuals Eligible in 1973 <sup> b </sup> </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> If age &lt; 65 years old </p> </td> </tr> <tr> <td> <p class=\"msword-table-text-left\"> 21: Working Disabled under 1619(b) <sup> a </sup> </p> <p class=\"msword-table-text-left\"> 24: Qualified Disabled and Working Individuals <sup> a </sup> </p> <p class=\"msword-table-text-left\"> 45: Qualified Disabled Children under Age 19 </p> <p class=\"msword-table-text-left\"> 47: Work Incentives Eligibility Group </p> <p class=\"msword-table-text-left\"> 48: Ticket to Work Basic Group </p> <p class=\"msword-table-text-left\"> 49: Ticket to Work Medical Improvements Group </p> <p class=\"msword-table-text-left\"> 50: Family Opportunity Act Children with Disabilities </p> <p class=\"msword-table-text-left\"> 69: Individuals with Mental Health Conditions (expansion group) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Any age </p> </td> </tr> </tbody></table><p class=\"msword-table-footnote\"> <a id=\"_Hlk112610766\"></a> <sup> a </sup> Eligibility group code represents Medicaid mandatory coverage</p><p class=\"msword-table-footnote\"> <sup> b </sup> Eligibility group code represents optional Medicaid medically needy coverage</p><p class=\"msword-paragraph\"> States must assign every Medicaid and CHIP beneficiary to one of the 72 eligibility groups, even if they meet the qualifications of more than one group. In cases where an applicant meets the qualifications of more than one eligibility group, Medicaid enrollment staff may decide the pathway through which the person gains eligibility. For example, a person who meets SSI eligibility criteria but has not already applied for SSI benefits or must go through the lengthy SSI appeals process may find it easier and/or quicker to obtain Medicaid coverage through an age- or income-based pathway. It may also be difficult to distinguish SSI recipients in states that rely on Medicaid eligibility groups that contain both recipients and non-recipients of SSI payments. For example, states may include SSI recipients and/or non-recipients in the Optional State Supplement Recipients eligibility groups (codes 40 and 41).</p><p class=\"msword-paragraph\"> There are two other variables in TAF that could be used to identify SSI receipt among Medicaid beneficiaries: SSI indicator and SSI status code. States use information collected in their eligibility and enrollment systems to populate these fields, but they are not necessarily part of the Medicaid eligibility determination process. It may be possible for individuals to be correctly coded in these fields as receiving SSI even if they qualify for Medicaid through a non-SSI eligibility pathway. For example, there could be cases where beneficiaries are identified as SSI recipients using SSI indicator or SSI status code and also identified as part of an Optional State Supplement Recipients eligibility group, which includes both SSI recipients and non-recipients.</p><p class=\"msword-paragraph\"> To understand the usability of eligibility group code and the two SSI variables in identifying Medicaid beneficiaries who receive SSI payments, we measure the extent to which the SSI population counts in TAF align with an external benchmark, the SSI Annual Statistical Report published by the SSA.</p><p class=\"msword-paragraph\"> The SSI Annual Statistical Report contains the number of all SSI beneficiaries, not all of which are enrolled in Medicaid. This is especially true in 209(b) states where Medicaid eligibility may only to apply to a subset of SSI recipients. In SSI criteria states, we would expect the number of SSI recipients in the TAF to be closer to but lower than in the SSA report (in theory, all SSI recipients in those states could receive Medicaid if they applied). However, in states that use 1634 agreements, we would expect very close alignment between the TAF and SSA numbers of SSI recipients.</p><ol> <li class=\"footnoteBody\" id=\"footnote-2\" value=\"1\"> <p class=\"msword-footnote-text\"> The SSI program also supports \"aged\" individuals from age 65. In this analysis, we focus on SSI recipients under age 65 because we can better disentangle eligibility based on disability versus eligibility based on age. </p> <p> <a href=\"#footnote-ref-2\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-3\" value=\"2\"> <p class=\"msword-footnote-text\"> SSA. Accessible at: <a aria-label=\"View Social Security Administration (SSA) Resource on the Disability Determination Process\" href=\"https://www.ssa.gov/disability/determination.htm\">https://www.ssa.gov/disability/determination.htm</a> . </p> <p> <a href=\"#footnote-ref-3\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-4\" value=\"3\"> <p class=\"msword-footnote-text\"> SSA. Accessible at: <a aria-label='View Social Security Administration (SSA) Factsheet: \"What You Should Know Before You Apply for Social Security Disability Benefits\"' href=\"https://www.ssa.gov/disability/Documents/Factsheet-AD.pdf\">https://www.ssa.gov/disability/Documents/Factsheet-AD.pdf</a> . </p> <p> <a href=\"#footnote-ref-4\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-5\" value=\"4\"> <p class=\"msword-footnote-text\"> SSA. Accessible at: <a aria-label=\"View Social Security Administration (SSA) Resource on Understanding the Supplemental Security Income Appeals Process\" href=\"https://www.ssa.gov/ssi/text-appeals-ussi.htm\">https://www.ssa.gov/ssi/text-appeals-ussi.htm</a> . </p> <p> <a href=\"#footnote-ref-5\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-6\" value=\"5\"> <p class=\"msword-footnote-text\"> Continuing disability reviews occur more frequently if the person&rsquo;s medical condition is expected to improve or other circumstances change (for example, the person returns to work or experiences an increase in wages). </p> <p> <a href=\"#footnote-ref-6\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-7\" value=\"6\"> <p class=\"msword-footnote-text\"> MACPAC. Accessible at: <a aria-label=\"View MACPAC topic on eligibility pathways for people with disabilities\" href=\"https://www.macpac.gov/subtopic/people-with-disabilities/\">https://www.macpac.gov/subtopic/people-with-disabilities/</a> . </p> <p> <a href=\"#footnote-ref-7\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-8\" value=\"7\"> <p class=\"msword-footnote-text\"> The 1972 amendments to the Social Security Act are accessible at: <a aria-label=\"View 1972 Amendments to the Social Security Act\" href=\"https://www.govinfo.gov/content/pkg/STATUTE-86/pdf/STATUTE-86-Pg1329.pdf\">https://www.govinfo.gov/content/pkg/STATUTE-86/pdf/STATUTE-86-Pg1329.pdf</a> . </p> <p> <a href=\"#footnote-ref-8\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-9\" value=\"8\"> <p class=\"msword-footnote-text\"> Historically, states reported the basis of eligibility in the legacy MSIS in two fields populated with the Maintenance Assistance Status (MAS) and Basis of Eligibility (BOE) codes. These codes were combined in T-MSIS but are no longer required fields. Although MAS/BOE may continue to be reported, fewer states are reporting this data element over time. In place of MAS and BOE, CMS developed a new coding system for classifying eligibility, known as the Eligibility Group, which is the focus of this assessment. </p> <p> <a href=\"#footnote-ref-9\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-10\" value=\"9\"> <p class=\"msword-footnote-text\"> For a full description of the eligibility groups, see the T-MSIS Data Dictionary Appendices, Version 2.4, Appendix F, p. 67, at <a aria-label=\"View the T-MSIS Data Dictionary Appendices\" href=\"https://www.medicaid.gov/medicaid/data-systems/downloads/tmsis-data-appendices.docx\">https://www.medicaid.gov/medicaid/data-systems/downloads/tmsis-data-appendices.docx</a> . </p> <p> <a href=\"#footnote-ref-10\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-11\" value=\"10\"> <p class=\"msword-footnote-text\"> Using 2019 TAF data, an average of 56 percent of beneficiaries under age 65 with disability-related eligibility group codes have one of the SSI eligibility codes (11, 12, or 13); however, the proportion attributed to codes 11, 12, and 13 varies from 2 percent (in Illinois) to 86 percent (in Missouri). </p> <p> <a href=\"#footnote-ref-11\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-12\" value=\"11\"> <p class=\"msword-footnote-text\"> Medicaid.gov. Accessible at: <a aria-label=\"View CMS Medicaid State Plan Eligibility Implementation Guidance on Mandatory Coverage Qualified Medicare Beneficiaries\" href=\"https://www.medicaid.gov/resources-for-states/downloads/macpro-ig-qualified-medicare-beneficiaries.pdf\">https://www.medicaid.gov/resources-for-states/downloads/macpro-ig-qualified-medicare-beneficiaries.pdf</a> . </p> <p> <a href=\"#footnote-ref-12\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-13\" value=\"12\"> <p class=\"msword-footnote-text\"> Medicaid.gov. Accessible at: <a aria-label=\"View CMS Medicaid State Plan Eligibility Implementation Guidance on Optional State Supplement Beneficiaries\" href=\"https://www.medicaid.gov/resources-for-states/downloads/macpro-ig-optional-state-supplement-beneficiaries.pdf\">https://www.medicaid.gov/resources-for-states/downloads/macpro-ig-optional-state-supplement-beneficiaries.pdf</a> . </p> <p> <a href=\"#footnote-ref-13\">&uarr;</a> </p> </li></ol>", "footnotes": [{"number": 2, "content": "<li class=\"footnoteBody\" id=\"footnote-2\" value=\"1\"><p class=\"msword-footnote-text\"> The SSI program also supports \"aged\" individuals from age 65. In this analysis, we focus on SSI recipients under age 65 because we can better disentangle eligibility based on disability versus eligibility based on age. </p><p><a href=\"#footnote-ref-2\">\u2191</a></p></li>"}, {"number": 3, "content": "<li class=\"footnoteBody\" id=\"footnote-3\" value=\"2\"><p class=\"msword-footnote-text\"> SSA. Accessible at: <a aria-label=\"View Social Security Administration (SSA) Resource on the Disability Determination Process\" href=\"https://www.ssa.gov/disability/determination.htm\">https://www.ssa.gov/disability/determination.htm</a> . </p><p><a href=\"#footnote-ref-3\">\u2191</a></p></li>"}, {"number": 4, "content": "<li class=\"footnoteBody\" id=\"footnote-4\" value=\"3\"><p class=\"msword-footnote-text\"> SSA. Accessible at: <a aria-label='View Social Security Administration (SSA) Factsheet: \"What You Should Know Before You Apply for Social Security Disability Benefits\"' href=\"https://www.ssa.gov/disability/Documents/Factsheet-AD.pdf\">https://www.ssa.gov/disability/Documents/Factsheet-AD.pdf</a> . </p><p><a href=\"#footnote-ref-4\">\u2191</a></p></li>"}, {"number": 5, "content": "<li class=\"footnoteBody\" id=\"footnote-5\" value=\"4\"><p class=\"msword-footnote-text\"> SSA. Accessible at: <a aria-label=\"View Social Security Administration (SSA) Resource on Understanding the Supplemental Security Income Appeals Process\" href=\"https://www.ssa.gov/ssi/text-appeals-ussi.htm\">https://www.ssa.gov/ssi/text-appeals-ussi.htm</a> . </p><p><a href=\"#footnote-ref-5\">\u2191</a></p></li>"}, {"number": 6, "content": "<li class=\"footnoteBody\" id=\"footnote-6\" value=\"5\"><p class=\"msword-footnote-text\"> Continuing disability reviews occur more frequently if the person\u2019s medical condition is expected to improve or other circumstances change (for example, the person returns to work or experiences an increase in wages). </p><p><a href=\"#footnote-ref-6\">\u2191</a></p></li>"}, {"number": 7, "content": "<li class=\"footnoteBody\" id=\"footnote-7\" value=\"6\"><p class=\"msword-footnote-text\"> MACPAC. Accessible at: <a aria-label=\"View MACPAC topic on eligibility pathways for people with disabilities\" href=\"https://www.macpac.gov/subtopic/people-with-disabilities/\">https://www.macpac.gov/subtopic/people-with-disabilities/</a> . </p><p><a href=\"#footnote-ref-7\">\u2191</a></p></li>"}, {"number": 8, "content": "<li class=\"footnoteBody\" id=\"footnote-8\" value=\"7\"><p class=\"msword-footnote-text\"> The 1972 amendments to the Social Security Act are accessible at: <a aria-label=\"View 1972 Amendments to the Social Security Act\" href=\"https://www.govinfo.gov/content/pkg/STATUTE-86/pdf/STATUTE-86-Pg1329.pdf\">https://www.govinfo.gov/content/pkg/STATUTE-86/pdf/STATUTE-86-Pg1329.pdf</a> . </p><p><a href=\"#footnote-ref-8\">\u2191</a></p></li>"}, {"number": 9, "content": "<li class=\"footnoteBody\" id=\"footnote-9\" value=\"8\"><p class=\"msword-footnote-text\"> Historically, states reported the basis of eligibility in the legacy MSIS in two fields populated with the Maintenance Assistance Status (MAS) and Basis of Eligibility (BOE) codes. These codes were combined in T-MSIS but are no longer required fields. Although MAS/BOE may continue to be reported, fewer states are reporting this data element over time. In place of MAS and BOE, CMS developed a new coding system for classifying eligibility, known as the Eligibility Group, which is the focus of this assessment. </p><p><a href=\"#footnote-ref-9\">\u2191</a></p></li>"}, {"number": 10, "content": "<li class=\"footnoteBody\" id=\"footnote-10\" value=\"9\"><p class=\"msword-footnote-text\"> For a full description of the eligibility groups, see the T-MSIS Data Dictionary Appendices, Version 2.4, Appendix F, p. 67, at <a aria-label=\"View the T-MSIS Data Dictionary Appendices\" href=\"https://www.medicaid.gov/medicaid/data-systems/downloads/tmsis-data-appendices.docx\">https://www.medicaid.gov/medicaid/data-systems/downloads/tmsis-data-appendices.docx</a> . </p><p><a href=\"#footnote-ref-10\">\u2191</a></p></li>"}, {"number": 11, "content": "<li class=\"footnoteBody\" id=\"footnote-11\" value=\"10\"><p class=\"msword-footnote-text\"> Using 2019 TAF data, an average of 56 percent of beneficiaries under age 65 with disability-related eligibility group codes have one of the SSI eligibility codes (11, 12, or 13); however, the proportion attributed to codes 11, 12, and 13 varies from 2 percent (in Illinois) to 86 percent (in Missouri). </p><p><a href=\"#footnote-ref-11\">\u2191</a></p></li>"}, {"number": 12, "content": "<li class=\"footnoteBody\" id=\"footnote-12\" value=\"11\"><p class=\"msword-footnote-text\"> Medicaid.gov. Accessible at: <a aria-label=\"View CMS Medicaid State Plan Eligibility Implementation Guidance on Mandatory Coverage Qualified Medicare Beneficiaries\" href=\"https://www.medicaid.gov/resources-for-states/downloads/macpro-ig-qualified-medicare-beneficiaries.pdf\">https://www.medicaid.gov/resources-for-states/downloads/macpro-ig-qualified-medicare-beneficiaries.pdf</a> . </p><p><a href=\"#footnote-ref-12\">\u2191</a></p></li>"}, {"number": 13, "content": "<li class=\"footnoteBody\" id=\"footnote-13\" value=\"12\"><p class=\"msword-footnote-text\"> Medicaid.gov. Accessible at: <a aria-label=\"View CMS Medicaid State Plan Eligibility Implementation Guidance on Optional State Supplement Beneficiaries\" href=\"https://www.medicaid.gov/resources-for-states/downloads/macpro-ig-optional-state-supplement-beneficiaries.pdf\">https://www.medicaid.gov/resources-for-states/downloads/macpro-ig-optional-state-supplement-beneficiaries.pdf</a> . </p><p><a href=\"#footnote-ref-13\">\u2191</a></p></li>"}]}, "methods": {"content": "<p class=\"msword-paragraph\"> We examined non-dummy enrollment records <sup class=\"msword-superscript\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-2\" id=\"footnote-ref-2\">[13]</a> </sup> </sup> in the TAF annual Demographic and Eligibility (DE) file. <sup class=\"msword-superscript\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-3\" id=\"footnote-ref-3\">[14]</a> </sup> </sup> To align with the benchmark data source, we identified SSI recipients in TAF during December of the given year. We limited the analysis to beneficiaries less than age 65, then tabulated the number of SSI recipients using each of three TAF variables as described in Table 3.</p><p class=\"msword-table-title\"> Table 3. Identification of SSI recipients in TAF</p><table aria-label=\"Table 3. Identification of SSI recipients in TAF\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Variable label </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Variable name </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Values to identify SSI recipients </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> Eligibility group code (month 12) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> ELGBLTY_GRP_CD_12 </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> 11, 12, 13 <sup> a </sup> </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> SSI indicator (month 12) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> SSI_IND_12 </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> 1 (Yes) </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> SSI status code (month 12) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> SSI_STUS_CD_12 </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> 001 (SSI) or 002 (SSI eligible spouse) </p> </td> </tr> </tbody></table><p class=\"msword-table-footnote\"> <sup> a </sup> Eligibility group codes 11, 12, and 13 should only be used for SSI recipients. We did not include beneficiaries in other eligibility groups that could contain SSI recipients because we could not distinguish them from non-recipients.</p><p class=\"msword-paragraph\"> To construct the benchmark, we used the Social Security Administration (SSA) SSI Annual Statistical Report, which contains information on the number of SSI recipients by age and state in December for a given year. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-4\" id=\"footnote-ref-4\">[15]</a> </sup> </sup> We summed the &ldquo;under 18&rdquo; and &ldquo;18-64&rdquo; age groups to determine the number of SSI recipients less than age 65.</p><p class=\"msword-paragraph\"> We first assessed data quality for each of the three TAF measures based on how well the number of SSI recipients aligned with the SSI Annual Statistical Report (Table 4). Then, the overall data quality assessment for each state was assigned based on the measure with the lowest data quality concern. For example, states in which any of the three measures were less than 10 percent different from the benchmark were classified as low concern, because there is at least one data element in TAF that can accurately identify SSI recipients with disabilities.</p><p class=\"msword-table-title\"> Table 4. Criteria for DQ assessment of ability to identify SSI recipients</p><table aria-label=\"Table 4. Criteria for DQ assessment of ability to identify SSI recipients\" class=\"dq-assessment-table\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Percent difference between TAF and SSI Annual Statistical Report </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Level of alignment </p> </th> <th class=\"msword-table-header-center dq-assessment-col\"> <p class=\"msword-table-header-center\"> DQ assessment </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &lt; 10 percent </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> High </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level low\"> <p class=\"msword-table-text-centered\"> Low concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 10 percent &le; x &lt; 20 percent </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Moderate </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level medium\"> <p class=\"msword-table-text-centered\"> Medium concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 20 percent &le; x &lt; 50 percent </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Low </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level high\"> <p class=\"msword-table-text-centered\"> High concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &ge; 50 percent </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Very low </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level unusable\"> <p class=\"msword-table-text-centered\"> Unusable </p> </td> </tr> </tbody></table><ol> <li class=\"footnoteBody\" id=\"footnote-2\" value=\"13\"> <p class=\"msword-footnote-text\"> We excluded DE records representing beneficiary IDs that are present on claims but were not included in the eligibility records submitted by the state (those with MISG_ELGBLTY_DATA_IND = 1). </p> <p> <a href=\"#footnote-ref-2\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-3\" value=\"14\"> <p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources page</a> , and a crosswalk of variable names can be found in the guide &ldquo;Production of the TAF Research Identifiable Files.&rdquo; </p> <p> <a href=\"#footnote-ref-3\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-4\" value=\"15\"> <p class=\"msword-footnote-text\"> The SSI Annual Statistical Report is available at <a aria-label=\"View the most recent SSI Annual Statistical Report\" href=\"https://www.ssa.gov/policy/docs/statcomps/ssi_asr/index.html\">https://www.ssa.gov/policy/docs/statcomps/ssi_asr/index.html</a> . In the 2020 report, this information was available in Table 10. </p> <p> <a href=\"#footnote-ref-4\">&uarr;</a> </p> </li></ol>", "footnotes": [{"number": 2, "content": "<li class=\"footnoteBody\" id=\"footnote-2\" value=\"13\"><p class=\"msword-footnote-text\"> We excluded DE records representing beneficiary IDs that are present on claims but were not included in the eligibility records submitted by the state (those with MISG_ELGBLTY_DATA_IND = 1). </p><p><a href=\"#footnote-ref-2\">\u2191</a></p></li>"}, {"number": 3, "content": "<li class=\"footnoteBody\" id=\"footnote-3\" value=\"14\"><p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources page</a> , and a crosswalk of variable names can be found in the guide \u201cProduction of the TAF Research Identifiable Files.\u201d </p><p><a href=\"#footnote-ref-3\">\u2191</a></p></li>"}, {"number": 4, "content": "<li class=\"footnoteBody\" id=\"footnote-4\" value=\"15\"><p class=\"msword-footnote-text\"> The SSI Annual Statistical Report is available at <a aria-label=\"View the most recent SSI Annual Statistical Report\" href=\"https://www.ssa.gov/policy/docs/statcomps/ssi_asr/index.html\">https://www.ssa.gov/policy/docs/statcomps/ssi_asr/index.html</a> . In the 2020 report, this information was available in Table 10. </p><p><a href=\"#footnote-ref-4\">\u2191</a></p></li>"}]}, "summary": {"content": "<p>One of the major pathways to qualify for Medicaid is through having a disabling condition. Low-income individuals with significant disabling conditions often receive Supplemental Security Income (SSI), which qualifies them for Medicaid in most states. This analysis examines how well the TAF can be used to identify Medicaid beneficiaries who receive SSI payments. Specifically, we compare the TAF to an external benchmark from the Social Security Administration (SSA), the SSI Annual Statistical Report.</p>", "footnotes": []}, "originalIssueBriefId": "4191", "relatedTopics": []}
123
{"measureId": 123, "measureName": "1115 Demonstration Identification", "groupId": 1, "groupName": "Enrollment Benchmarking", "pdfVersionLink": "downloads/background-and-methods/TAF-DQ-1115-Demo-ID.pdf", "background": {"content": "<p class=\"msword-paragraph\"> Section 1115 of the Social Security Act provides the Secretary of Health and Human Services with broad authority to waive federal Medicaid requirements and allow states to make changes to their Medicaid programs as long as they are likely to promote the objectives of the Medicaid program. <a id=\"_Hlk116906954\"></a> As of October 2022, there were 79 approved section 1115 demonstrations in 47 states and the District of Columbia. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-2\" id=\"footnote-ref-2\">[1]</a> </sup> </sup> These demonstrations vary greatly in size and scope. States can change policies for existing Medicaid populations, expand coverage for certain groups or benefits, authorize new types of Medicaid payments, and test other approaches. Some section 1115 demonstrations encompass most or all Medicaid beneficiaries in the states, and others focus on only a small subset of Medicaid beneficiaries or a discrete feature of the program. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-3\" id=\"footnote-ref-3\">[2]</a> </sup> </sup></p><p class=\"msword-paragraph\"> TAF were designed to make it easier to identify participants in all types of waiver programs, including section 1115 demonstrations and 1915(b) and 1915(c) waivers. Each beneficiary enrolled in at least one Medicaid waiver in any month during the calendar year has a record in the annual Demographic and Eligibility (DE) Waiver Supplemental file. The Waiver Supplemental file includes information about each specific waiver type (WVR_TYPE_CD) and waiver ID (WVR_ID) for up to 10 waivers under which the eligible beneficiary received services for each month during the calendar year. It also includes high-level summary data elements to represent the most recent Medicaid section 1115 demonstration type (_1115_WVR_TYPE) during the year and how many months a beneficiary was enrolled in various types of section 1115 demonstrations (Table 1).</p><p class=\"msword-table-title\"> Table 1. TAF data elements that could serve to identify participants in section 1115 demonstration programs</p><table aria-label=\"Table 1. TAF data elements that could serve to identify participants in section 1115 demonstration programs\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> TAF data element </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> File </p> </th> <th class=\"\"> <p> <strong> How data element helps identify section 1115 demonstration IDs </strong> </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> WVR_TYPE_CD </p> </td> <td> <p class=\"msword-table-text-centered\"> DE (Waiver) </p> <p class=\"msword-table-text-centered\"> BSF </p> <p class=\"msword-table-text-centered\"> IP (Header) </p> <p class=\"msword-table-text-centered\"> LT (Header) </p> <p class=\"msword-table-text-centered\"> OT (Header) </p> <p class=\"msword-table-text-centered\"> RX (Header) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> In the DE and BSF files, this code indicates the waiver type under which the eligible beneficiary is covered and receiving services for up to 10 waivers for each month during the calendar year. In the claims files, this code indicates the waiver type under which the claim was paid. Waiver codes that correspond to section 1115 demonstrations include \"01\" and \"21-30\". </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> _1115_WVR_TYPE <sup class=\"msword-footnote-reference\"> a </sup> </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> DE (Waiver) </p> </td> <td> <p class=\"msword-table-text-centered\"> This data element represents the type of section 1115 demonstration under which the beneficiary most recently received coverage, and it is not associated with a duration of enrollment (that is, the coverage could have been for any number of days during the year). A beneficiary can be identified as a section 1115 demonstration participant during the calendar year if there is a non-null value in this field. </p> <p class=\"msword-table-text-centered\"> The DE Waiver Supplemental file also includes how many months a beneficiary was enrolled in various types of section 1115 demonstrations: Pharmacy Plus demonstrations (_1115_PHRMCY_PLUS_WVR_MOS), Disaster-related demonstrations (_1115_DSTR_REL_WVR_MOS), Family Planning only demonstrations (_1115_FP_ONLY_WVR_MOS), Health Insurance Flexibility and Accountability (HIFA) demonstrations (_1115_HIFA_WVR_MOS), and Other research and demonstration (_1115_OTHR_WVR_MOS). </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> WVR_ID </p> </td> <td> <p class=\"msword-table-text-centered\"> DE (Waiver) </p> <p class=\"msword-table-text-centered\"> APL (Operating Authority) </p> <p class=\"msword-table-text-centered\"> BSF </p> <p class=\"msword-table-text-centered\"> IP (Header) </p> <p class=\"msword-table-text-centered\"> LT (Header) </p> <p class=\"msword-table-text-centered\"> MCP (Base) </p> <p class=\"msword-table-text-centered\"> OT (Header) </p> <p class=\"msword-table-text-centered\"> RX (Header) </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> In the DE and BSF files, this data element provides the specific federal waiver ID in which the beneficiary was enrolled. In the APL file, this data element is the operating authority(or authorities) through which the managed care entity receives its contract authority and specifies the federal waiver ID that authorized payment for a claim. In the claims files, this data element provides the specific federal waiver ID that authorized payment for a claim. These IDs must be the approved full federal waiver ID number assigned during the state submission and the approval process of the Centers for Medicare &amp; Medicaid Services. </p> </td> </tr> </tbody></table><p class=\"msword-table-footnote\"> <a id=\"_Hlk135719462\"></a> <a id=\"_Hlk135718924\"></a> <sup class=\"msword-footnote-reference\"> a </sup> In the Annual DE Waiver Supplemental File, Section 1115A demonstration participation indicator (SECT_1115A_DEMO_IND_01-12) refers to a CMS Innovation Center demonstration and should not be confused with the Medicaid Section 1115(a) waiver type (_1115_WVR_TYPE).</p><p class=\"msword-table-footnote\"> Note: The waiver type and waiver ID data elements are available monthly in the TAF DE, with the number of waivers (up to 10) and each month (1-12) appended to the end of the data element name (for instance, WVR_ID1_01 for the first waiver ID in January, WVR_ID10_12 for the 10th waiver ID in December, and so on). For simplicity, we did not list the monthly indicators in this analysis because we used all months of data. A list of valid values and descriptions of these data elements is available in the TAF Demographic and Eligibility Codebook at&nbsp; <a aria-label=\"View the TAF Claims Codebook on the Chronic Conditions Data Warehouse Data Dictionaries page\" href=\"https://www2.ccwdata.org/web/guest/data-dictionaries\">https://www2.ccwdata.org/web/guest/data-dictionaries</a> .</p><p class=\"msword-table-footnote\"> <br/></p><p class=\"msword-paragraph\"> Although the waiver type code is currently designed to identify 11 different types of section 1115 demonstrations, TAF users are discouraged from relying upon it to identify participants in <em> specific </em> types of section 1115 demonstrations. Many states code all their section 1115 demonstrations as code 01 (representing the non-specific \"Other 1115(a) Medicaid research and evaluation demonstrations\"), and several waiver type codes are not reported by any state. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-4\" id=\"footnote-ref-4\">[3]</a> </sup> </sup> Instead, TAF users are encouraged to use the waiver ID data element to identify Medicaid beneficiaries participating in <em> specific </em> section 1115 demonstrations.</p><p class=\"msword-paragraph\"> This data quality assessment compares the waiver IDs representing section 1115 demonstrations found in TAF with administrative data that states report to the Centers for Medicare &amp; Medicaid Services (CMS) on active section 1115 demonstrations in each state. We confirm whether the full federal demonstration number assigned to each unique section 1115 demonstration is accurately reported in TAF. We also identify when a state reports a waiver ID in T-MSIS that couldn&rsquo;t be matched with the set of active section 1115 demonstration numbers in the CMS administrative data.</p><ol> <li class=\"footnoteBody\" id=\"footnote-2\" value=\"1\"> <p class=\"msword-footnote-text\"> Centers for Medicare &amp; Medicaid Services. \"State Waiver List.\" 2021. <a aria-label=\"View State Waivers List\" href=\"https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/index.html\">https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/index.html</a> . Accessed October 12, 2022. </p> <p> <a href=\"#footnote-ref-2\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-3\" value=\"2\"> <p class=\"msword-footnote-text\"> Medicaid and CHIP Payment and Access Commission. \"Section 1115 Demonstration Budget Neutrality.\" December 2021. <a aria-label=\"View MACPAC Issue Brief on Section 1115 Demonstration Budget Neutrality\" href=\"https://www.macpac.gov/wp-content/uploads/2021/12/Section-1115-Demonstration-Budget-Neutrality.pdf\">https://www.macpac.gov/wp-content/uploads/2021/12/Section-1115-Demonstration-Budget-Neutrality.pdf</a> . Accessed October 12, 2022. </p> <p> <a href=\"#footnote-ref-3\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-4\" value=\"3\"> <p class=\"msword-footnote-text\"> The other 10 section 1115 waiver type codes are 21 - 1115 Health Insurance Flexibility and Accountability (HIFA) demonstration; 22 - 1115 Pharmacy demonstration; 23 - 1115 Disaster-related demonstration; 24 - 1115 Family planning demonstration; 25 - 1115 Substance use demonstration; 26 - 1115 Premium Assistance demonstration; 27 - 1115 Beneficiary engagement demonstration; 28 - 1115 Former foster care youth from another state; 29 - 1115 Managed long term services and support; and 30 - 1115 Delivery system reform. </p> <p> <a href=\"#footnote-ref-4\">&uarr;</a> </p> </li></ol>", "footnotes": [{"number": 2, "content": "<li class=\"footnoteBody\" id=\"footnote-2\" value=\"1\"><p class=\"msword-footnote-text\"> Centers for Medicare &amp; Medicaid Services. \"State Waiver List.\" 2021. <a aria-label=\"View State Waivers List\" href=\"https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/index.html\">https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/index.html</a> . Accessed October 12, 2022. </p><p><a href=\"#footnote-ref-2\">\u2191</a></p></li>"}, {"number": 3, "content": "<li class=\"footnoteBody\" id=\"footnote-3\" value=\"2\"><p class=\"msword-footnote-text\"> Medicaid and CHIP Payment and Access Commission. \"Section 1115 Demonstration Budget Neutrality.\" December 2021. <a aria-label=\"View MACPAC Issue Brief on Section 1115 Demonstration Budget Neutrality\" href=\"https://www.macpac.gov/wp-content/uploads/2021/12/Section-1115-Demonstration-Budget-Neutrality.pdf\">https://www.macpac.gov/wp-content/uploads/2021/12/Section-1115-Demonstration-Budget-Neutrality.pdf</a> . Accessed October 12, 2022. </p><p><a href=\"#footnote-ref-3\">\u2191</a></p></li>"}, {"number": 4, "content": "<li class=\"footnoteBody\" id=\"footnote-4\" value=\"3\"><p class=\"msword-footnote-text\"> The other 10 section 1115 waiver type codes are 21 - 1115 Health Insurance Flexibility and Accountability (HIFA) demonstration; 22 - 1115 Pharmacy demonstration; 23 - 1115 Disaster-related demonstration; 24 - 1115 Family planning demonstration; 25 - 1115 Substance use demonstration; 26 - 1115 Premium Assistance demonstration; 27 - 1115 Beneficiary engagement demonstration; 28 - 1115 Former foster care youth from another state; 29 - 1115 Managed long term services and support; and 30 - 1115 Delivery system reform. </p><p><a href=\"#footnote-ref-4\">\u2191</a></p></li>"}]}, "methods": {"content": "<p> <a id=\"_Hlk135719805\"></a> Using the TAF, <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-2\" id=\"footnote-ref-2\">[4]</a> </sup> </sup> we examine records from the TAF annual DE Waiver Supplemental file. To identify beneficiaries covered under a section 1115 demonstration, we looked at WVR_TYPE_CD and counted the beneficiary as a section 1115 demonstration participant if there is at least one waiver type code indicating enrollment in a section 1115 demonstration (WVR_TYPE_CD_01_01 - WVR_TYPE_CD_10_12 =\"01\" or \"21-30\") in any month during the year. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-3\" id=\"footnote-ref-3\">[5]</a> </sup> </sup> For each waiver type code identified as a section 1115 demonstration, we looked up the corresponding waiver ID for the same beneficiary in the same month. We then compiled and counted all unique waiver IDs associated with a section 1115 demonstration by state.</p><p> <a id=\"_Hlk116590393\"></a> We used an extract from the section 1115 demonstration PMDA as the benchmark data to examine the accuracy of the waiver IDs representing section 1115 demonstrations found in TAF. The PMDA system is a web-based application that allows states to submit data on section 1115 demonstrations to the Centers for Medicaid and CHIP Services (CMCS). CMCS tracks state applications for new demonstrations, amendments, and extensions and monitors post-approval demonstrations for whether states achieved desired outcomes and projected cost savings through PMDA. Although the PMDA system is the authoritative source for section 1115 demonstration administration, it has several limitations for benchmarking purposes: (1) because states report quarter or annual time periods based on their demonstration implementation dates, those periods do not necessarily align with the calendar year; (2) reports are submitted quarterly, but states often run into delays submitting data for a variety of reasons; and (3) the reports are not audited, although CMS staff review them in comparison with each state&rsquo;s approved demonstration program to determine whether reporting requirements were <a id=\"_Hlk116590551\"></a> met. Only reports CMS accepts are reflected in these benchmarks.</p><p> <a id=\"_Hlk116590584\"></a> A benchmark data set is created by extracting the demonstration name, demonstration number, and start and end dates of demonstration performance period from the PMDA system for every section 1115 demonstration active during the calendar year. We then perform a two-part assessment for each state that compares the demonstration number for the active section 1115 demonstrations in a state in the benchmark data with the waiver ID representing section 1115 demonstrations as reported in the DE Waiver Supplemental file. First, we assessed whether every section 1115 demonstration number in the benchmark data were present for at least one beneficiary in that state&rsquo;s TAF data. Second, we assessed whether there were any unexpected waiver IDs in TAF that were not present in the benchmark data. States in which expected demonstration numbers were missing from TAF, or for which waiver ID values were present in TAF that were not found in the benchmark data, were assessed as having higher levels of data quality concern (Table 2). Occasionally, a demonstration starts late in a year and might have little time to enroll beneficiaries. Regardless of the effective dates, all active section 1115 demonstrations during a calendar year are counted in this analysis. We make an exception, however, to the data quality assessment criteria for demonstrations in the first year of performance if they have a late effective date (defined as October 1 or later)&mdash; <a id=\"_Hlk133573366\"></a> if all a state has in the PMDA system are section 1115 demonstrations with late effective date, we consider it unclassified (that is, its data quality will be assessed in the next calendar year). If a state has multiple section 1115 demonstrations and only some have a late effective date, whether we find a match in TAF for these demonstrations with late effective date does not carry any weight in the data quality assessment. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-4\" id=\"footnote-ref-4\">[6]</a> </sup> </sup></p><p class=\"msword-table-title\"> Table 2. <a id=\"_Hlk34816350\"></a> Criteria for DQ assessment of 1115 Demonstration Identification</p><table aria-label=\"Table 2. Criteria for DQ assessment of 1115 Demonstration Identification\" class=\"dq-assessment-table\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-row-head\"> <p class=\"msword-table-row-head\"> Proportion of unique waiver IDs present in TAF that are expected <sup> a </sup> </p> </th> <th class=\"msword-table-row-head\"> <p class=\"msword-table-row-head\"> Number of unique waiver IDs present in TAF that are unexpected </p> </th> <th class=\"msword-table-row-head dq-assessment-col\"> <p class=\"msword-table-row-head\"> DQ assessment </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> All </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> None </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level low\"> <p class=\"msword-table-text-centered\"> Low concern </p> </td> </tr> <tr> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> All </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Some (1 or more) </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level medium\"> <p class=\"msword-table-text-centered\"> Medium concern </p> </td> </tr> <tr> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> More than half but not all </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Any value </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level medium\"> <p class=\"msword-table-text-centered\"> Medium concern </p> </td> </tr> <tr> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Half or fewer </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Any value </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level high\"> <p class=\"msword-table-text-centered\"> High concern </p> </td> </tr> <tr> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> None </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> Any value </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level unusable\"> <p class=\"msword-table-text-centered\"> Unusable </p> </td> </tr> </tbody></table><p class=\"msword-table-source\"> <sup> a </sup> If a state has no section 1115 demonstrations in the TAF or the PMDA system, or only &ldquo;late start&rdquo; demonstrations in the PMDA system, the DQ assessment is unclassified.</p><ol> <li class=\"footnoteBody\" id=\"footnote-2\" value=\"4\"> <p class=\"msword-footnote-text\"> This analysis used the TAF data released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. More details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources page</a> , and a crosswalk of variable names are available in the guide called Production of the TAF Research Identifiable Files. <a aria-label=\"View TAF Methodology Brief on the Production of the TAF Research Identifiable Files\" class=\"bgm-relative-link\" href=\"downloads/supplemental/9010-Production-of-TAF-RIF.pdf\">https://www.medicaid.gov/dq-atlas/downloads/supplemental/9010-Production-of-TAF-RIF.pdf</a> . Accessed October 12, 2022. </p> <p> <a href=\"#footnote-ref-2\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-3\" value=\"5\"> <p class=\"msword-footnote-text\"> States are not reporting the specific type of section 1115 waiver code reliably. Although waiver type code cannot be used to identify the specific type of section 1115 waiver for a state, it can serve to differentiate a section 1115 waiver from other waiver programs. </p> <p> <a href=\"#footnote-ref-3\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-4\" value=\"6\"> <p class=\"msword-footnote-text\"> There could be multiple reasons why a state has not reported an expected section 1115 demonstration number in its T-MSIS data, some of which relate to data quality (for example, a typo in reporting the demonstration number or not being able to capture enrollment in specific demonstration at all), but others might be driven by a specific policy or program context, and having a late effective date during a calendar year is only one of them. </p> <p> <a href=\"#footnote-ref-4\">&uarr;</a> </p> </li></ol>", "footnotes": [{"number": 2, "content": "<li class=\"footnoteBody\" id=\"footnote-2\" value=\"4\"><p class=\"msword-footnote-text\"> This analysis used the TAF data released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. More details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources page</a> , and a crosswalk of variable names are available in the guide called Production of the TAF Research Identifiable Files. <a aria-label=\"View TAF Methodology Brief on the Production of the TAF Research Identifiable Files\" class=\"bgm-relative-link\" href=\"downloads/supplemental/9010-Production-of-TAF-RIF.pdf\">https://www.medicaid.gov/dq-atlas/downloads/supplemental/9010-Production-of-TAF-RIF.pdf</a> . Accessed October 12, 2022. </p><p><a href=\"#footnote-ref-2\">\u2191</a></p></li>"}, {"number": 3, "content": "<li class=\"footnoteBody\" id=\"footnote-3\" value=\"5\"><p class=\"msword-footnote-text\"> States are not reporting the specific type of section 1115 waiver code reliably. Although waiver type code cannot be used to identify the specific type of section 1115 waiver for a state, it can serve to differentiate a section 1115 waiver from other waiver programs. </p><p><a href=\"#footnote-ref-3\">\u2191</a></p></li>"}, {"number": 4, "content": "<li class=\"footnoteBody\" id=\"footnote-4\" value=\"6\"><p class=\"msword-footnote-text\"> There could be multiple reasons why a state has not reported an expected section 1115 demonstration number in its T-MSIS data, some of which relate to data quality (for example, a typo in reporting the demonstration number or not being able to capture enrollment in specific demonstration at all), but others might be driven by a specific policy or program context, and having a late effective date during a calendar year is only one of them. </p><p><a href=\"#footnote-ref-4\">\u2191</a></p></li>"}]}, "summary": {"content": "<p>Medicaid section 1115 demonstration waivers encourage innovation by letting states test policies that depart from existing federal rules as long as they promote the objectives of the Medicaid program and are budget neutral to the federal government. When beneficiaries participate in a section 1115 demonstration, states must report the waiver type and the waiver ID number as part of the beneficiary's eligibility information submitted in the Transformed Medicaid Statistical Information System (T-MSIS). This analysis examines how well the section 1115 demonstration IDs in the T-MSIS Analytic Files (TAF) align with an external benchmark, the state-submitted demonstration monitoring data on the Performance Metrics Database and Analytics (PMDA) system.</p>", "footnotes": []}, "originalIssueBriefId": "4211", "relatedTopics": []}
124
{"measureId": 124, "measureName": "American Indian and Alaska Native Indicator", "groupId": 3, "groupName": "Beneficiary Information", "pdfVersionLink": "downloads/background-and-methods/TAF-DQ-AI-AN-Ind.pdf", "background": {"content": "<p class=\"msword-paragraph\"> The T MSIS Analytic Files (TAF) are research-optimized data on beneficiaries enrolled in Medicaid and the Children&rsquo;s Health Insurance Program (CHIP). The Annual Demographic and Eligibility (DE) file contains information on beneficiary demographic characteristics, including whether the beneficiary meets the definition of an American Indian/Alaska Native.</p><p class=\"msword-paragraph\"> States use the American Indian or Alaska Native (AI/AN) indicator to report a beneficiary&rsquo;s status as an AI/AN individual. The valid values for these data elements are listed in Table 1 below.</p><p class=\"msword-table-title\"> Table 1. Valid values for the AI/AN indicator in TAF</p><table aria-label=\"Table 1. Valid values for the AI/AN indicator in TAF\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Variable </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Description </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Valid Values <sup> b </sup> </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> CRTFD_AMRCN_INDN_ALSKN_NTV_IND <sup> a </sup> </p> </td> <td> <p class=\"msword-table-text-left\"> &ldquo;American Indian or Alaska Native&rdquo; means any beneficiary defined at 25 USC 1603(13), 1603(28), or 1679(a), or who has been determined eligible as an Indian, pursuant to 42 CFR &sect; 136.12. This means the beneficiary: </p> <ul> <li class=\"msword-table-list-bullet\"> Is a member of a Federally-recognized Indian tribe; </li> <li class=\"msword-table-list-bullet\"> Resides in an urban center and meets one or more of the following four criteria: (1) Is a member of a tribe, band, or other organized group of Indians, including those tribes, bands, or groups terminated since 1940 and those recognized now or in the future by the State in which they reside, or who is a descendant, in the first or second degree, of any such member; (2) Is an Eskimo or Aleut or other Alaska Native; (3) Is considered by the Secretary of the Interior to be an Indian for any purpose; or (4) Is determined to be an Indian under regulations promulgated by the `Secretary of Health and Human Services; </li> <li class=\"msword-table-list-bullet\"> Is considered by the Secretary of the Interior to be an Indian for any purpose; or </li> <li class=\"msword-table-list-bullet\"> Is considered by the Secretary of Health and Human Services to be an Indian for purposes of eligibility for Indian health care services, including as a California Indian, Eskimo, Aleut, or other Alaska Native; most recent in the calendar and the two prior years </li> </ul> </td> <td> <p class=\"msword-table-text-left\"> 0 = Individual does not meet the definition of an American Indian/Alaska Native </p> <p class=\"msword-table-text-left\"> 1 = Individual meets the definition of an American Indian/Alaska Native </p> </td> </tr> </tbody></table><p class=\"msword-table-footnote\"> <sup class=\"msword-footnote-reference\"> a </sup> In the TAF RIF, this data element is called CRTFD_AMRCN_INDN_ALSKN_NTV_CD. Starting in 2025, this data element name will be updated in TAF and TAF RIF.</p><p class=\"msword-table-footnote\"> <sup> b </sup> As of February 14, 2020 the value of 2 for &ldquo;Yes individual does have CDIB&rdquo; (Certificate of Degree of Indian Blood) has been retired from T-MSIS and is no longer considered valid.</p><p class=\"msword-paragraph\"> Members of federally recognized Indian tribes and individuals who are otherwise eligible for services from an Indian health care provider are eligible for certain Medicaid and CHIP protections related to premiums, enrollment fees, and cost sharing. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-2\" id=\"footnote-ref-2\">[1]</a> </sup> </sup> While AI/AN identity is self-reported on Medicaid applications, states typically verify the beneficiary&rsquo;s AI/AN status before reporting the AI/AN indicator in TAF. However, each state undergoes a different verification process, which may result in variation or inconsistency in reporting the data element. For example, some states require proof of tribal membership or affiliation, evidence of receipt of services or referrals to an Indian health provider, or other types of documentation to be submitted, whereas other states may accept an individual&rsquo;s self-attestation. Although states are expected to report the information that they receive on the beneficiary&rsquo;s AI/AN status, some states may not submit complete information because the data were not collected or technical difficulties arose in reporting.</p><p class=\"msword-paragraph\"> This data quality assessment tabulates the proportion of records in the DE file that have missing information for the certified AI/AN indicator. For additional context, this analysis also measures the extent to which state reporting of the AI/AN indicator aligns with values reported using the race/ethnicity code in TAF and with an external benchmark, the American Community Survey (ACS) 5-year estimates.</p><ol> <li class=\"footnoteBody\" id=\"footnote-2\" value=\"1\"> <p class=\"msword-footnote-text\"> For more information about Medicaid and CHIP coverage for American Indian and Alaska Native individuals, refer to: <a aria-label=\"View CMS Resource on Health Coverage Options for American Indians and Alaska Natives\" href=\"https://www.cms.gov/marketplace/technical-assistance-resources/AIAN-health-coverage-options.pdf\">https://www.cms.gov/marketplace/technical-assistance-resources/AIAN-health-coverage-options.pdf</a> </p> <p> <a href=\"#footnote-ref-2\">&uarr;</a> </p> </li></ol>", "footnotes": [{"number": 2, "content": "<li class=\"footnoteBody\" id=\"footnote-2\" value=\"1\"><p class=\"msword-footnote-text\"> For more information about Medicaid and CHIP coverage for American Indian and Alaska Native individuals, refer to: <a aria-label=\"View CMS Resource on Health Coverage Options for American Indians and Alaska Natives\" href=\"https://www.cms.gov/marketplace/technical-assistance-resources/AIAN-health-coverage-options.pdf\">https://www.cms.gov/marketplace/technical-assistance-resources/AIAN-health-coverage-options.pdf</a></p><p><a href=\"#footnote-ref-2\">\u2191</a></p></li>"}]}, "methods": {"content": "<p class=\"msword-paragraph\"> We examined the American Indian or Alaska Native (AI/AN) Indicator (CRTFD_AMRCN_INDN_ALSKN_NTV_IND) on non-dummy enrollment records <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-2\" id=\"footnote-ref-2\">[2]</a> </sup> </sup> in the TAF annual Demographic and Eligibility (DE) file. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-3\" id=\"footnote-ref-3\">[3]</a> </sup> </sup> We tabulated proportion with missing or invalid values for AI/AN indicator and assessed data quality for the AI/AN indictor based on this measure (Table 2). We considered any value that is not 0 (Individual does not meet the definition of an American Indian/Alaska Native) or 1 (Individual meets the definition of an American Indian/Alaska Native) to be missing or invalid. In addition, if a state reported no AI/AN beneficiaries in TAF based on the AI/AN indicator, we deemed the data quality assessment to be unusable. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-4\" id=\"footnote-ref-4\">[4]</a> </sup> </sup></p><p class=\"msword-table-title\"> Table 2. <a id=\"_Hlk34816350\"></a> Criteria for DQ assessment of AI/AN Indicator</p><table aria-label=\"Table 2. Criteria for DQ assessment of AI/AN Indicator\" class=\"dq-assessment-table\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> Percentage of records with missing or invalid AI/AN indicator values </p> </th> <th class=\"msword-table-header-center dq-assessment-col\"> <p class=\"msword-table-header-center\"> DQ assessment </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &le; 10 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level low\"> <p class=\"msword-table-text-centered\"> Low concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 10 percent &lt; x &le; 20 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level medium\"> <p class=\"msword-table-text-centered\"> Medium concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 20 percent &lt; x &le; 50 percent </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level high\"> <p class=\"msword-table-text-centered\"> High concern </p> </td> </tr> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> x &gt; 50 percent or no AI/AN beneficiaries reported in TAF </p> </td> <td class=\"msword-table-text-centered dq-assessment-col dq-level unusable\"> <p class=\"msword-table-text-centered\"> Unusable </p> </td> </tr> </tbody></table><p class=\"msword-paragraph\"> We also calculated two sets of contextual measures to investigate the extent to which state reporting of American Indian and Alaska Native individuals using the AI/AN indicator aligns with (1) reporting of the condensed race/ethnicity code (RACE_ETHNCTY_FLAG) in TAF and (2) American Community Survey (ACS) data.</p><p class=\"msword-paragraph\"> It is expected that for most cases, the value reported in the AI/AN indicator variable should align with an individual&rsquo;s race/ethnicity reported in TAF (a race/ethnicity code value of 4 in TAF indicates American Indian/Alaska Native). However, the AI/AN indicator variable does not separate beneficiaries based on ethnicity or multiracial identity, whereas the AI/AN value for the combined race/ethnicity variable in TAF specifies non-Hispanic, mono-racial AI/AN individuals. In addition, while both the AI/AN indicator and race/ethnicity rely primarily on self-identification, states often require supplemental verification when reporting the AI/AN indicator. Therefore, it is expected that there will be some level of expected misalignment between AI/AN indicator and race/ethnicity in TAF. For context, we calculated and displayed: (1) the percentage of beneficiaries reported as AI/AN based on the AI/AN indicator value without a corresponding race/ethnicity value, (2) the percentage of beneficiaries reported as AI/AN based on the race/ethnicity code value without a corresponding AI/AN indicator value, and (3) the overall percentage of all TAF beneficiary records for which either of the two previously described scenarios applied. Given the known differences between the AI/AN indicator and race/ethnicity variables, these measures are displayed for context only to help TAF users explore additional potential data quality issues and are not included in calculation of the data quality assessment.</p><p class=\"msword-paragraph\"> We also compared the AI/AN beneficiary counts using the AI/AN indicator in TAF to an external benchmark, the ACS. We used the ACS 5-year estimates <sup class=\"msword-superscript\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-5\" id=\"footnote-ref-5\">[5]</a> </sup> </sup> Public Use Microdata Sample (PUMS) <sup class=\"msword-superscript\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-6\" id=\"footnote-ref-6\">[6]</a> </sup> </sup> for a given year. <sup class=\"msword-footnote-reference\"> <sup> <a class=\"footnoteRef\" href=\"#footnote-7\" id=\"footnote-ref-7\">[7]</a> </sup> </sup> The ACS data, which are collected annually from a nationally representative random sample of households, contains information on self-reported race, ethnicity, and health insurance coverage. After pulling the ACS microdata from PUMS, we selected all individuals who reported having &ldquo;Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low incomes or a disability&rdquo; at the time of the survey. For individuals in that group, we calculated the percentage who were AI/AN (Table 3). We did not subset this population by ethnicity.</p><p class=\"msword-paragraph\"> ACS data is used by many stakeholders, including by federal and state government agencies for policy and program funding activities, and are considered a highly reliable source of demographic data. There are, however, several reasons for there to be a discrepancy in AI/AN identification between ACS and TAF data. The ACS data do not include individuals who identify with two or more races in the AI/AN count. Self-reporting of health insurance coverage and AI/AN status for the ACS can result in an undercount or overcount of the number of AI/AN Medicaid beneficiaries who appear in administrative data, whereas reporting of AI/AN indicator in TAF often relies on verification of an individual&rsquo;s AI/AN status. In this analysis, we compare the percentage of Medicaid beneficiaries with AI/AN indicator value of 1 in TAF to the comparable distribution in the ACS. Given the known differences between the TAF and ACS definitions of AI/AN, we presented these measures for context only and did not include them in the calculation of the data quality assessment.</p><p class=\"msword-table-title\"> Table 3. AI/AN categories in TAF and ACS</p><table aria-label=\"Table 3. AI/AN categories in TAF and ACS\" tabindex=\"0\"> <thead> <tr> <th class=\"msword-table-header-left\"> <p class=\"msword-table-header-left\"> AI/AN indicator value in TAF </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Race/ethnicity code value in TAF <sup> a </sup> </p> </th> <th class=\"msword-table-header-center\"> <p class=\"msword-table-header-center\"> Race variables in the ACS </p> </th> </tr> </thead> <tbody> <tr> <td class=\"msword-table-text-left\"> <p class=\"msword-table-text-left\"> 1 = Individual meets the definition of an American Indian/Alaska Native </p> </td> <td class=\"msword-table-text-centered\"> <p class=\"msword-table-text-centered\"> 4 = American Indian and Alaska Native (AIAN), non-Hispanic </p> </td> <td> <ul> <li class=\"msword-table-list-bullet\"> American Indian alone </li> <li class=\"msword-table-list-bullet\"> Alaska Native alone </li> <li class=\"msword-table-list-bullet\"> American Indian and Alaska Native tribes specified; or American Indian or Alaska native, not specified and no other races </li> </ul> </td> </tr> </tbody></table><p class=\"msword-table-footnote\"> <sup> a </sup> For the race/ethnicity flag TAF, a &ldquo;non-Hispanic&rdquo; value may indicate that (1) the beneficiary is not Hispanic or (2) the beneficiary&rsquo;s ethnicity or Hispanic status is not reported.</p><ol> <li class=\"footnoteBody\" id=\"footnote-2\" value=\"2\"> <p class=\"msword-footnote-text\"> We excluded DE records representing beneficiary IDs that are present on claims but were not included in the eligibility records submitted by the state (those with MISG_ELGBLTY_DATA_IND = 1). </p> <p> <a href=\"#footnote-ref-2\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-3\" value=\"3\"> <p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources page</a> , and a crosswalk of variable names can be found in the guide &ldquo;Production of the TAF Research Identifiable Files.&rdquo; </p> <p> <a href=\"#footnote-ref-3\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-4\" value=\"4\"> <p class=\"msword-footnote-text\"> All states included in the ACS have a non-zero number of AI/AN individuals who also identified as a Medicaid enrollee. Therefore, if a state reports zero AI/AN beneficiaries in TAF, this likely indicates a data quality issue. </p> <p> <a href=\"#footnote-ref-4\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-5\" value=\"5\"> <p class=\"msword-footnote-text\"> <a id=\"_Hlk47010181\"></a> <a id=\"_Hlk47010182\"></a> ACS 5-year estimates are more reliable and complete than ACS 1-year estimates and the Current Population Survey, as it includes smaller geographic areas and has a larger sample size. For more details, see: <a aria-label=\"View American Community Survey Guidance for Data Users: When to Use 1-year or 5-year Estimates\" href=\"https://www.census.gov/programs-surveys/acs/guidance/estimates.html\">https://www.census.gov/programs-surveys/acs/guidance/estimates.html</a> and <a aria-label=\"View a Health Services Research article on The American Community Survey and Health Insurance Coverage Estimates\" href=\"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2677056/\">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2677056/</a> </p> <p> <a href=\"#footnote-ref-5\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-6\" value=\"6\"> <p class=\"msword-footnote-text\"> <a aria-label=\"Explore the American Community Survey data\" href=\"https://data.census.gov/mdat/#/\">https://data.census.gov/mdat/#/</a> </p> <p> <a href=\"#footnote-ref-6\">&uarr;</a> </p> </li> <li class=\"footnoteBody\" id=\"footnote-7\" value=\"7\"> <p class=\"msword-footnote-text\"> For example, to compare against the 2022 TAF data, we used the ACS 5-year estimates for 2022 that are based on data collected between 2018 and 2022. </p> <p> <a href=\"#footnote-ref-7\">&uarr;</a> </p> </li></ol>", "footnotes": [{"number": 2, "content": "<li class=\"footnoteBody\" id=\"footnote-2\" value=\"2\"><p class=\"msword-footnote-text\"> We excluded DE records representing beneficiary IDs that are present on claims but were not included in the eligibility records submitted by the state (those with MISG_ELGBLTY_DATA_IND = 1). </p><p><a href=\"#footnote-ref-2\">\u2191</a></p></li>"}, {"number": 3, "content": "<li class=\"footnoteBody\" id=\"footnote-3\" value=\"3\"><p class=\"msword-footnote-text\"> This analysis used the TAF data that were released as TAF Research Identifiable Files (RIF). During the transformation into RIF, some TAF data elements were suppressed, changed, or renamed. Additional details are available on the <a aria-label=\"View additional details on the DQ Atlas Resources page\" class=\"bgm-relative-link\" href=\"landing/resources\">DQ Atlas Resources page</a> , and a crosswalk of variable names can be found in the guide \u201cProduction of the TAF Research Identifiable Files.\u201d </p><p><a href=\"#footnote-ref-3\">\u2191</a></p></li>"}, {"number": 4, "content": "<li class=\"footnoteBody\" id=\"footnote-4\" value=\"4\"><p class=\"msword-footnote-text\"> All states included in the ACS have a non-zero number of AI/AN individuals who also identified as a Medicaid enrollee. Therefore, if a state reports zero AI/AN beneficiaries in TAF, this likely indicates a data quality issue. </p><p><a href=\"#footnote-ref-4\">\u2191</a></p></li>"}, {"number": 5, "content": "<li class=\"footnoteBody\" id=\"footnote-5\" value=\"5\"><p class=\"msword-footnote-text\"><a id=\"_Hlk47010181\"></a><a id=\"_Hlk47010182\"></a> ACS 5-year estimates are more reliable and complete than ACS 1-year estimates and the Current Population Survey, as it includes smaller geographic areas and has a larger sample size. For more details, see: <a aria-label=\"View American Community Survey Guidance for Data Users: When to Use 1-year or 5-year Estimates\" href=\"https://www.census.gov/programs-surveys/acs/guidance/estimates.html\">https://www.census.gov/programs-surveys/acs/guidance/estimates.html</a> and <a aria-label=\"View a Health Services Research article on The American Community Survey and Health Insurance Coverage Estimates\" href=\"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2677056/\">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2677056/</a></p><p><a href=\"#footnote-ref-5\">\u2191</a></p></li>"}, {"number": 6, "content": "<li class=\"footnoteBody\" id=\"footnote-6\" value=\"6\"><p class=\"msword-footnote-text\"><a aria-label=\"Explore the American Community Survey data\" href=\"https://data.census.gov/mdat/#/\">https://data.census.gov/mdat/#/</a></p><p><a href=\"#footnote-ref-6\">\u2191</a></p></li>"}, {"number": 7, "content": "<li class=\"footnoteBody\" id=\"footnote-7\" value=\"7\"><p class=\"msword-footnote-text\"> For example, to compare against the 2022 TAF data, we used the ACS 5-year estimates for 2022 that are based on data collected between 2018 and 2022. </p><p><a href=\"#footnote-ref-7\">\u2191</a></p></li>"}]}, "summary": {"content": "<p>The TAF eligibility files include information on select demographic characteristics of beneficiaries enrolled in Medicaid or CHIP. This analysis examines the completeness of the American Indian and Alaska Native indicator information in the TAF. For additional context, this analysis also presents information on how well the TAF data on American Indian and Alaska Native indicator align with an external benchmark, the U.S. Census Bureau's American Community Survey, and race/ethnicity values in TAF.</p>", "footnotes": []}, "originalIssueBriefId": "4221", "relatedTopics": []}