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Medicaid Fee-For-Service Study Appendices

Medicaid FFS Study Appendices

A.1 - A.9
A.10 - A.15

A.1: Medicaid FFS Study Participants

Organization Description of Role
Comptroller of Public Accounts Provided overall project management. Solicited bids and selected a contractor for the study. Evaluated and enhanced study design from the first study. Coordinated project meetings and interviews, and information requests from all agencies involved with the Medicaid, State Employees Workers' Compensation and Medicaid Managed Care studies. Compiled and validated all study information received. Worked with consultants on aspects of the study, including completing information sheets, assisting with medical record review, and resolving issues as they arose.
Ethel Ponson, R.N. Professional nurse utilization reviewer. Reviewed online claim information and medical record documentation received from providers for the study. Assisted with the compilation of the results and the interagency medical record review meetings.
ECS Consultants Professional nurse utilization reviewer. Reviewed online claim information and medical record documentation received from providers for the study. Assisted with the compilation of the results and the interagency medical record review meetings.
Health and Human Services Commission (HHSC) Office of Eligibility Services (OES) Mailed the notification/information request letters to the Medicaid sample clients. Coordinated the Medicaid provider medical record request mail-outs. Received and tracked the medical records for delivery to the Comptroller's Office. Responded to the Medicaid providers' inquiry calls. Coordinated TDH, NHIC, physician and dental agency reviews of the Medicaid medical records.
National Heritage Insurance Company (02-03 HHSC Medicaid Claims Administration Contractor) Created the Medicaid sampling program and collected the sample report data using the study criteria developed by the Medicaid study project team. Compiled the sample universe data and fiscal claim data.
State Auditors Office (SAO) Provided assistance with evaluating and enhancing the Medicaid study methodology. Validated the Medicaid sample universe data. Performed the overpayment rate
computation.

Appendix A.2: Comparison of the December 1998, January 2001, March 2003 and March 2005 Medicaid Sections of the Texas Health Care Claims Studies

The table below compares the criterion of the last four studies published by the Comptroller's office.

Criteria December 1998 Study January 2001 Study March 2003 Study March 2005 Study
Sample Size (Original sample size planned was 700, however, the Vendor Drug category was eliminated due to issues with collecting the data to review) 700 800 800
Number of Sample Services 1,043 1,916 2,122 2,202
Sample Time Period Services rendered in November 1997 and paid through January 19, 1998. Services rendered from September 1, 1999, through November 30, 1999 and paid through February 4, 2000. Services rendered from September 1, 2001, through November 30, 2001 and paid through January 7, 2002. Services rendered from September 1, 2002, through November 30, 2002 and paid through January 7, 2003.
Sample Service Exclusions Encounter data for Health Maintenance Organizations Long Term Care Encounter data for Health Maintenance Organizations Long Term Care Encounter data for Health Maintenance Organizations Long Term Care Encounter data for Health Maintenance Organizations Long Term Care
Sample Provider Exclusions Texas Commission for Alcohol and Drug Abuse Clinics

Mental Retardation Diagnostic and Case Management

Mental Health Diagnostic and Case Management

Early Childhood Intervention

THSteps (Texas Health Steps) previously known as EPSDT (Early and Periodic Screening, Diagnosis and Treatment)

Individual Texas Education Agency

Psychiatric Hospitals

Rehabilitation Centers and Hospitals

EPSDT/Health Department Mobile Units Regional

Genetics

Nephrology

Renal Dialysis Facilities

Tuberculosis Clinic

Durable Medical Equipment for Medicare only

Military Hospitals
Texas Commission for Alcohol and Drug Abuse Clinics

Durable Medical Equipment for Medicare only

Military Hospitals

Individual Texas Education Agency
Texas Commission for Alcohol and Drug Abuse Clinics

Medicare Only Providers

Military Hospitals

Individual Texas Education Agency

Providers under active investigation by the Health and Human Services Commission's Office of Investigation and Enforcement and Texas Attorney General's Office
Texas Commission for Alcohol and Drug Abuse Clinics

Medicare Only Providers

Military Hospitals

Individual Texas Education Agency

Providers under active investigation by the Health and Human Services Commission's Office of Inspector General and Texas Attorney General's Office
Sampling Selection Program A random selection of detailed services from claims paid in the Medicaid Management Information System (MMIS). These were selected from ten stratified categories: five categories with 100 sample days and five categories of 20 sample days. A random selection of detailed services from claims paid in the Medicaid Management Information System (MMIS). These were selected from seven stratified categories, each with 100 sample days. A random selection of detailed services from claims paid in the Medicaid Management Information System (MMIS). These were selected from eight stratified categories, each with 100 sample days. A random selection of detailed services from claims paid in the Medicaid Management Information System (MMIS). These were selected from eight stratified categories, each with 100 sample days
Sampling Replacement No patient days were replaced; however, if all the services for a client on their sample day were paid to a provider under investigation, no review was undertaken for any of these services. No patient days were replaced; however, if all the services for a client on their sample day were paid to a provider under investigation, no review was undertaken for any of these services. No patient days were replaced. No patient days were replaced.
Patient Telephone Interviews Telephone interviews were attempted for all patients with a telephone number. Telephone interviews were conducted by a professional telephone survey firm. Texas Health and Human Services Commission (HHSC) investigators and Comptroller field staff attempted face-to-face interviews with patients who could not be interviewed by phone. Telephone interviews were attempted for all patients with a telephone number. Telephone interviews were conducted by a professional telephone survey firm. Face-to-face interviews were not conducted. Extensive efforts were taken to identify active telephone numbers to contact the clients. Telephone interviews were attempted for all patients with a telephone number. Telephone interviews were conducted by a professional telephone survey firm. Face-to-face interviews were not conducted. Extensive efforts were taken to identify active telephone numbers to contact the clients. Telephone interviews were not performed due to previous studies unreliable results.
Contextual Data Analysis Online review) Analysts reviewed a three-month period of claims surrounding the patient day on-site at HHSC using the National Heritage Insurance Company's (NHIC) on-line Medicaid Management Information System (MMIS). Analysts reviewed a four-month period of claims, surrounding the patient day on-site at TDH using the National Heritage Insurance Company's (NHIC) on-line system (MMIS). Analysts reviewed a four-month period of claims, surrounding the patient day using the National Heritage Insurance Company's (NHIC) on-line system Phoenix application implemented August 2001. Analysts reviewed a four-month period of claims, surrounding the patient day using the on-line claim processing system known as
Phoenix.
Medical Records Review Medical records were requested when a problem was noted in either the patient interview or the contextual data analysis. Not all medical records were received. Analysts conducted an initial review in preparation for forwarding records to a medical review organization. However, the study concluded before all records were reviewed. A subsequent review was conducted by the HHSC and the State Auditor's Office. Medical records for the entire sample were requested at the beginning of the study. Professional nurses from the Study team and HHSC reviewed all records to verify services were rendered. Services with medical necessity questions were additionally reviewed by a HHSC physician reviewer. Medical records for the entire sample were requested at the beginning of the study. Professional nurses from the Study team and HHSC reviewed all records to verify services were rendered. Services with medical necessity questions were additionally reviewed by a HHSC physician reviewer.. Medical records for the entire sample were requested at the beginning of the study. Professional nurses from the Study team and HHSC reviewed all records to verify services were rendered. Services with medical necessity questions were additionally reviewed by a HHSC physician reviewer.

Appendix A.3: U.S. Department of Health and Human Services Health Care Financing Administration List of Medicaid Eligibility Groups

The federal Medicaid law identifies certain populations that states are required to cover and other populations that states may choose to cover.1

Required Medicaid Eligibility Groups:

All states must provide Medicaid coverage to the following eligibility groups:

  • Individuals are generally eligible for Medicaid if they meet the requirements for the Aid to Families with Dependent Children (AFDC) program that were in effect in their State on July 16, 1996.
  • Children under age 6 whose family income is at or below 133 percent of the Federal poverty level (FPL).
  • Pregnant women whose family income is below 133 percent of the FPL (services to these women are limited to those related to pregnancy, complications of pregnancy, delivery, and postpartum care).
  • Supplemental Security Income (SSI) clients in most States (some States use more restrictive Medicaid eligibility requirements that pre-date SSI).
  • Clients of adoption or foster care assistance under Title IV of the Social Security Act.
  • Special protected groups (typically individuals who lose their cash assistance due to earnings from work or from increased Social Security benefits, but who may keep Medicaid for a period of time).
  • All children born after September 30, 1983 who are under age 19, in families with incomes at or below the FPL.
  • Certain Medicare beneficiaries: State Medicaid programs must provide assistance to low-income Medicare beneficiaries. All Medicare beneficiaries with incomes below the poverty level receive Medicaid assistance for payment of Medicare premiums, deductibles and cost sharing. These individuals are Qualified Medicare Beneficiaries. In addition, individuals at the lowest income levels are entitled to full Medicaid benefits which provide coverage for services not covered by Medicare such as outpatient prescription drugs. Medicare beneficiaries with income levels slightly higher than the poverty level receive Medicaid assistance for payment of Medicare premiums. These individuals are Specified Low-Income Medicare Beneficiaries and Qualified Individuals.

Optional Medicaid Eligibility Groups

States have the option to provide Medicaid coverage to other groups. These optional groups fall within the defined categories mentioned above but the financial eligibility standards are more liberally defined. he broadest optional groups for which States will receive Federal matching funds for coverage under the Medicaid program include the following:

  • Infants up to age 1 and pregnant women not covered under the mandatory rules whose family income is no more than 185 percent of the FPL (the percentage amount is set by each State).
  • Children under age 21 who meet criteria more liberal than the AFDC income and resources requirements that were in effect in their State on July 16, 1996.
  • Institutionalized individuals eligible under a "special income level" (the amount is set by each State-up to 300 percent of the SSI Federal benefit rate).
  • Individuals who would be eligible if institutionalized, but who are receiving care under home and community-based services (HCBS) waivers.
  • Certain aged, blind, or disabled adults who have incomes above those requiring mandatory coverage, but below the FPL.
  • Clients of State supplementary income payments.
  • Certain working-and-disabled persons with family income less than 250 percent of the FPL who would qualify for SSI if they did not work.
  • TB-infected persons who would be financially eligible for Medicaid at the SSI income level if they were within a Medicaid-covered category (however, coverage is limited to TB-related ambulatory services and TB drugs).
  • Certain uninsured or low-income women who are screened for breast or cervical cancer through a program administered by the Centers for Disease Control. The Breast and Cervical Cancer Prevention and Treatment Act of 2000 (Public Law 106-354) provides these women with medical assistance and follow-up diagnostic services through Medicaid.
  • "Optional targeted low-income children" included within the State Children's Health Insurance Program (SCHIP) established by the Balanced Budget Act (BBA) of 1997 (Public Law 105-33).
  • "Medically needy" persons - the medically needy (MN) option allows States to extend Medicaid eligibility to additional persons. These persons would be eligible for Medicaid under one of the mandatory or optional groups, except that their income and/or resources are above the eligibility level set by their State. Persons may qualify immediately or may "spend down" by incurring medical expenses that reduce their income to or below their State's MN income level.

1Centers for Medicare & Medicaid Services, "Medicaid: A Brief Summary", December 3, 2004, http://www.cms.hhs.gov/publications/overview-medicare-medicaid/default4.asp. (Last visited January 20, 2005).

Appendix A.4: U.S. Department of Health and Human Services Health Care Financing Administration List Of Medicaid Mandatory And Optional Covered Services

The federal requirements define the Medicaid benefit package for each state. Each state's Medicaid program must cover "mandatory services" identified in statute. There are an additional 33 optional services that states may include in their covered services. Both the mandatory and optional services are listed in the table below.1

Mandatory Services Most Common of the Thirty-four Currently Approved Optional Medicaid Services
  • Inpatient hospital services.
  • Outpatient hospital services.
  • Prenatal care.
  • Vaccines for children.
  • Physician services.
  • Nursing facility services for persons aged 21 or older.
  • Family planning services and supplies.
  • Rural health clinic services.
  • Home health care for persons eligible for skilled-nursing services.
  • Laboratory and x-ray services.
  • Pediatric and family nurse practitioner services.
  • Nurse-midwife services.
  • Federally qualified health-center (FQHC) services, and ambulatory services of an FQHC that would be available in other settings.
  • Early and periodic screening, diagnostic, and treatment (EPSDT) services for children under age 21.
  • Diagnostic services.
  • Clinic services.
  • Intermediate care facilities for the mentally retarded (ICFs/MR).
  • Prescribed drugs and prosthetic devices.
  • Optometrist services and eyeglasses.
  • Nursing facility services for children under age 21.
  • Transportation services.
  • Rehabilitation and physical therapy services.
  • Home and community-based care to certain persons with chronic impairments.

1Centers for Medicare & Medicaid Services, "Medicaid: A Brief Summary", December 3, 2004, http://www.cms.hhs.gov/publications/overview-medicare-medicaid/default4.asp. (Last visited January 20, 2005).

Appendix A.5: Texas Health and Human Services Commission Medicaid Organization Chart


 Texas Health and Human Services Commission Medicaid Organization Chart part 1

Appendix A.6: Texas Medicaid Eligibility Groups

The Texas Medicaid Program provides all the federally required eligible groups, defined in Appendix A.5, and the optional eligible groups listed below:

Required Eligibility Groups

  • Individuals are generally eligible for Medicaid if they meet the requirements for the Aid to Families with Dependent Children (AFDC) program that were in effect in their State on July 16, 1996.
  • Children under age 6 whose family income is at or below 133 percent of the Federal poverty level (FPL).
  • Pregnant women whose family income is below 133 percent of the FPL (services to these women are limited to those related to pregnancy, complications of pregnancy, delivery, and postpartum care).
  • Supplemental Security Income (SSI) clients in most States (some States use more restrictive Medicaid eligibility requirements that pre-date SSI).
  • Clients of adoption or foster care assistance under Title IV of the Social Security Act.
  • Special protected groups (typically individuals who lose their cash assistance due to earnings from work or from increased Social Security benefits, but who may keep Medicaid for a period of time).
  • All children born after September 30, 1983 who are under age 19, in families with incomes at or below the FPL.
  • Certain Medicare beneficiaries.1

Optional Eligibility Groups

  • Long Term Care;
  • Pregnant women and infants with family incomes up to 185 percent of FPL;1
  • Presumptive Eligibility - Temporary Medicaid coverage to pregnant women whose family income does not exceed the state's Medicaid limit. The intent is to provide the earliest possible access to prenatal care to improve maternal and child health. Clients with presumptive eligibility receive immediate, short-term Medicaid eligibility while their formal Medicaid application is processed;2 and
  • Medically Needy - provides Medicaid benefits to individuals and families whose income exceeds the eligibility limits under Temporary Assistance for Needy Families or one of the Medical Assistance Only (MAO) programs for children and pregnant women but is not enough to meet their medical expenses. Coverage is available for services within the amount, duration, and scope of the Texas Medicaid Program.3

    1Centers for Medicare & Medicaid Services, "Medicaid: A Brief Summary", December 3, 2004, http://www.cms.hhs.gov/publications/overview-medicare-medicaid/default4.asp. (Last visited January 20, 2005)..

    2Texas Health and Human Services Commission, National Heritage Insurance Company, 2003 Texas Medicaid Provider Procedures Manual (Austin, Texas), pp. 1-8.

    3Texas Health and Human Services Commission, National Heritage Insurance Company, 2003 Texas Medicaid Provider Procedures Manual (Austin, Texas), pp. 1-10.

A.7: Texas Medicaid Covered Services

The Texas Medicaid Program provides all the federally mandatory services along with the optional services listed in the table below:1

Mandatory Services Optional Services
  • Inpatient hospital services.
  • Outpatient hospital services.
  • Prenatal care.
  • Vaccines for children.
  • Physician services.
  • Nursing facility services for persons aged 21 or older.
  • Family planning services and supplies.
  • Rural health clinic services.
  • Home health care for persons eligible for skilled-nursing services.
  • Laboratory and x-ray services.
  • Pediatric and family nurse practitioner services.
  • Nurse-midwife services.
  • Federally qualified health-center (FQHC) services, and ambulatory services of an FQHC that would be available in other settings.
  • Early and periodic screening, diagnostic, and treatment (EPSDT) services for children under age 21.
  • Advance Practice Nurse
  • Ambulance
  • Birthing Center
  • Case Management for Blind and Visually Impaired Children (BVIC)
  • Case Management for Early Childhood Intervention (ECI)
  • Case Management for High-Risk Pregnant Women and Infants (PWI)
  • Certified Registered Nurse Anesthetist (CRNA)
  • Certified Respiratory Care Practitioner (CRCP)
    Services
  • Chemical Dependency Treatment Facility
  • Chiropractic Services
  • Dental Services*
  • Family Planning Services
  • Genetics
  • Hearing Aid
  • Texas Medicaid Home Health Services
  • In-Home Total Parenteral Hyperalimentation Supplier
  • Licensed Master Social Workers-Advanced Clinical Practitioner (LMSW-ACP)
  • Licensed Professional Counselors (LPCs)
  • Maternity Service Clinic (MSC)
  • Mental Health (MH) Mental Retardation (MR)
  • Military Hospital
  • Physical Therapy
  • Psychologists
  • Renal Dialysis Facility
  • School Health and Related Services (SHARS)
  • THSteps Comprehensive Care Program (CCP) Services
  • Tuberculosis (TB) Clinics
  • Vision Care (Optometrists, Opticians)2

* There is no general dental coverage for adults in the Texas Medicaid Program. Dental services are provided to children, residents of Intermediate Care Facilities for the Mentally Retarded age 21 and over, adults with dental-related problems secondary to a life-threatening medical problem and adult residents in nursing home facilities who require emergency services.
1 Texas Health and Human Services Commission, National Heritage Insurance Company, 2003 Texas Medicaid Provider Procedures Manual (Austin, Texas), p. 1-8
2 Texas Health and Human Services Commission, National Heritage Insurance Company, 2003 Texas Medicaid Provider Procedures Manual (Austin, Texas), TOC-ii

Appendix A.8: Texas Medicaid FFS Study Categories

2003 - 2004 Medicaid Study Categories with Provider Type/Specialty Codes & Descriptions
Ancillary/Outpatient = 100 sample claims by patient day
Ancillary: 23& 24/69 Independent lab
43/98 Radiation Treatment Center
75/30, 63&69 Portable X-ray Supplier
Outpatient:
15/A4 CCP Outpatient Clinic
46/70 FQHC
51&52/49 Ambulatory Surgery Center
52/81 & 53/50 Birthing Center
55/68 Maternity Service Clinic
52/81, 56/08&70 Comprehensive Health Center
66/49&70 Texas Health Steps Medical Clinics
71/60 Family Planning Clinic
78/77 Rural Health Center
79/85 Rural Health Center
Dental = 100 sample claims by patient day
27/19 Dentist
48/19 EPSDT Dentist
90/19 Orthodontist
91/19 Oral Maxillofacial Surgeon
92/19 Dental Group
96/19 EPSDT Dental Group
Home Health = 100 sample claims by patient day
44/61 Home Health Agency
Hospitals = 100 sample claims by patient day
50/81 Hospital - Teaching Affiliate
50/93 Hospital - Other, Out-of-State
60&61/80 Children's Hospitals
60/82, 84, 90&92 Hospital - Long term, Specialized
60/83, &86 Acute, Profit
60/89&91 Acute, Non-profit
60/92 Acute Long Term Hospital, Ltd or spec care, Non-profit
60 & 61/93 Long Term Care Hospital, Out-of-State
61/81 Teaching
61/83 Private Acute, Profit
61/81, 84&86 Private Acute, Profit
61/89, 90, 91& 92 Private Acute, Non-profit
62/80, 82&93 Outpatient, Emergency Care
Mental Health = 100 sample claims by patient day
16/A5 LPC/LPC-CCP
18/A7 Social Worker-CCP
31/62 Psychologist
09/46 MR Diagnostic/Case Management
12/47 Mental Health Rehabilitation/Case Management
64/80, 82, F1&F2Psychiatric Hospital
74/26 Mental Health Clinic
97/62 Psychology Group
Other/Other Health Care Professionals = 100 sample claims by patient day
Ambulance
42/59 Ambulance Chiropractors
30/35 Chiropractor
94/35 Chiropractor Group
Podiatrist
32/48 Podiatrist
95/48 Podiatrist Group Physical Therapy
34/25&65 Physical Therapist
35/25 Occupational Therapist
98/65 Physical Therapy Group Optometry
28/88 Optometrist
93/88 Optometrist Group Other Health Professionals
04 & 05/43 CRNA
06/58 Respiratory Therapist
07/A9, 46, 47, 68&87 Case Manager
33/75 RN/Nurse Midwife
37/64 Audiologist
38/52, 53, 56, 57&58 Prosthetist
39/53, 55, 57&58 Orthotist
50/66 CCP Providers
50/A0 Speech Therapy, CCP
50/A1 RN-CCP
50/A2 LVN-CCP
10/08 FNP/PNP
Other Health Care Providers
03/70 County Indigent Health Care Program Clinic
11/25 Early childhood intervention/Physical medicine and rehab
13/70 Individual TEA provider
14/70 CCP Group Multi-specialty Clinic
36/A0&70 Speech and Hearing Clinic
46/73 Federally Qualified Health Clinic (FQHC)
47/73&93 Nursing Home
49/76 Nurse Anesthetist
65/25&F3 Rehab Center
65/82 Rehab Hospital
66/44 EPSDT/Health Dept. Mobile Units & Regional
66/45 EPSDT
68/67 Genetics
69 Indian Health Services (EOPM table)
72/39&F4 Nephrology
73/39& 82 Renal Dialysis Facility
80 Nursing Home SNF (Skilled Nursing Facility) (EOPM table)
AA/70 School Health & Related Services(SHARS) Multi-specialty Clinic
AB & AC/B3 TB Clinic
CIHCP providers
CC/CC Coordinated Care
Physicians = 100 sample claims by patient day
Types 19, 20, 21 & 22/all specialties M.D. & D.O.
25/30 M.D. Radiologist
Type 66/all specialties Texas Health Steps Medical
Supplies/DME = 100 sample claims by patient day
Medical Supplies - DME*
17/A8&61 Home Health DME
26/54&87 Pharmacy medical supplier
40/all specialties Medical/DME supplier
54/51, 52, 53&54 Medical Supply Company
58/55, 56, 57&58 Individual Medical Supplier
69/18&19 Drug & Department Store Medical supplier
83/54&87 Oxygen Supplier
84/02, 03, 04, 08, 17, 54 & 64 Hearing Aid
Vision Services
29/51, 52, 53&54 Optician/Optical Company
Do Not Sample
08/70 TACADA Multi-specialty Clinic
64/F6 Psychiatric Hospital Audiologist (Medicare crossovers only)
DA/CB HMO
DE/B2 Military Hospitals
FH/FH Funeral Home
HF/HF Hemophilia Factor
SC/SC Seating Clinic

Appendix A.9: Texas Medicaid FFS Study Sampling Procedure

Step 1 (SQL) - Pull claims from which the sample records will be chosen as defined by requestor:

  • Source SQL: $libr01.axapahqp.step1a Output data: $daw105.pdapadpm.ah3062un
  • Source SQL: $libr01.axapahqp.step1b Output data: $daw105.pdapadpm.ah3062un
  • Source SQL: $libr01.axapahqp.step1c Output data: $daw105.pdapadpm.ah3062un

(CT23: pulling billing provider information with detail claim information)

Step 2 (C) - Randomly choose 1 record per client from sample universe:

  • Input data: $daw105.pdapadpm.ah3062un
  • Output data: $daw105.pdapadpm.ah3062ur
  • Program: $libr02.aoaphext.krandip
  • Define Setup: $libr02.axapddef.ah3062df
  • Batch file: $libr01.pdapahqp.step2

Step 3 (SQL)- Separate claims into categories based on Provider Type and Specialty:

  • Add CLAIM_FLAG = S
  • Add RANDOM_DATE = '3999-12-31'
  • Input data: $DAW105.PDAPADPM.AH3062UR

Source SQL: $LIBR01.AXAPAHQP.step3C1
Source SQL: $LIBR01.AXAPAHQP.step3C2
Source SQL: $LIBR01.AXAPAHQP.step3C3
Source SQL: $LIBR01.AXAPAHQP.step3C4
Source SQL: $LIBR01.AXAPAHQP.step3C5
Source SQL: $LIBR01.AXAPAHQP.step3C6
Source SQL: $LIBR01.AXAPAHQP.step3C7
Source SQL: $LIBR01.AXAPAHQP.step3C8
Output data: $DAW105.PDAPADPM.C1UN3062
Output data: $DAW105.PDAPADPM.C2UN3062
Output data: $DAW105.PDAPADPM.C3UN3062
Output data: $DAW105.PDAPADPM.C4UN3062
Output data: $DAW105.PDAPADPM.C5UN3062
Output data: $DAW105.PDAPADPM.C6UN3062
Output data: $DAW105.PDAPADPM.C7UN3062
Output data: $DAW105.PDAPADPM.C8UN3062

Step 4 (C) - Randomly choose 200 sample records from each category (8) AND Randomly chose one date of service from the range of service dates on each record to produce the record Patient day.

Input data: $DAW105.PDAPADPM.C1UN3062
Input data: $DAW105.PDAPADPM.C2UN3062
Input data: $DAW105.PDAPADPM.C3UN3062
Input data: $DAW105.PDAPADPM.C4UN3062
Input data: $DAW105.PDAPADPM.C5UN3062
Input data: $DAW105.PDAPADPM.C6UN3062
Input data: $DAW105.PDAPADPM.C7UN3062
Input data: $DAW105.PDAPADPM.C8UN3062
Output data: $DAW105.PDAPADPM.C1S3062
Output data: $DAW105.PDAPADPM.C2S3062
Output data: $DAW105.PDAPADPM.C3S3062
Output data: $DAW105.PDAPADPM.C4S3062
Output data: $DAW105.PDAPADPM.C5S3062
Output data: $DAW105.PDAPADPM.C6S3062
Output data: $DAW105.PDAPADPM.C7S3062
Output data: $DAW105.PDAPADPM.C8S3062
Program: $libr02.aoaphext.randcgl
Batch file: $libr01.pdapahqp.step4
Define Setup: $libr02.axapddef.ah3062dfn

Step 5 (SQL) - Divide sample records into sets of 100:

  • Code: $libr01.pdapahqp.step5

Output: $DAW105.PDAPADPM.C1S3062A
Output: $DAW105.PDAPADPM.C1S3062B
Output: $DAW105.PDAPADPM.C2S3062A
Output: $DAW105.PDAPADPM.C2S3062B
Output: $DAW105.PDAPADPM.C3S3062A
Output: $DAW105.PDAPADPM.C3S3062B
Output: $DAW105.PDAPADPM.C4S3062A
Output: $DAW105.PDAPADPM.C4S3062B
Output: $DAW105.PDAPADPM.C5S3062A
Output: $DAW105.PDAPADPM.C5S3062B
Output: $DAW105.PDAPADPM.C6S3062A
Output: $DAW105.PDAPADPM.C6S3062B
Output: $DAW105.PDAPADPM.C7S3062A
Output: $DAW105.PDAPADPM.C7S3062B
Output: $DAW105.PDAPADPM.C8S3062A
Output: $DAW105.PDAPADPM.C8S3062B

Sample process complete

Step 6 (SQL) - Pull associated Inpatient and Outpatient claims to sample records for each category sample set:

Source SQL: $LIBR01 AXAPAHQP.A1A3062O
Source SQL: $LIBR01 AXAPAHQP.A1B3062O
Source SQL: $LIBR01 AXAPAHQP.A1A3062I
Source SQL: $LIBR01 AXAPAHQP.A1B3062I
Source SQL: $LIBR01 AXAPAHQP.A2A3062O
Source SQL: $LIBR01 AXAPAHQP.A2B3062O
Source SQL: $LIBR01 AXAPAHQP.A2A3062I
Source SQL: $LIBR01 AXAPAHQP.A2B3062I
Source SQL: $LIBR01 AXAPAHQP.A3A3062O
Source SQL: $LIBR01 AXAPAHQP.A3B3062O
Source SQL: $LIBR01 AXAPAHQP.A3A3062I
Source SQL: $LIBR01 AXAPAHQP.A3B3062I
Source SQL: $LIBR01 AXAPAHQP.A4A3062O
Source SQL: $LIBR01 AXAPAHQP.A4B3062O
Source SQL: $LIBR01 AXAPAHQP.A4A3062I
Source SQL: $LIBR01 AXAPAHQP.A4B3062I
Source SQL: $LIBR01 AXAPAHQP.A5A3062O
Source SQL: $LIBR01 AXAPAHQP.A5B3062O
Source SQL: $LIBR01 AXAPAHQP.A5A3062I
Source SQL: $LIBR01 AXAPAHQP.A5B3062I
Source SQL: $LIBR01 AXAPAHQP.A6A3062O
Source SQL: $LIBR01 AXAPAHQP.A6B3062O
Source SQL: $LIBR01 AXAPAHQP.A6A3062I
Source SQL: $LIBR01 AXAPAHQP.A6B3062I
Source SQL: $LIBR01 AXAPAHQP.A7A3062O
Source SQL: $LIBR01 AXAPAHQP.A7B3062O
Source SQL: $LIBR01 AXAPAHQP.A7A3062I
Source SQL: $LIBR01 AXAPAHQP.A7B3062I
Source SQL: $LIBR01 AXAPAHQP.A8A3062O
Source SQL: $LIBR01 AXAPAHQP.A8B3062O
Source SQL: $LIBR01 AXAPAHQP.A8A3062I
Source SQL: $LIBR01 AXAPAHQP.A8B3062I

Output data: $DAW105.PDAPADPM.A1A3062O
(Associated records, category 1, set A, outpatient claims)
Output data: $DAW105.PDAPADPM.A1B3062O
(Associated records, category 1, set B, outpatient claims)
Output data: $DAW105.PDAPADPM.A1A3062I
(Associated records, category 1, set A, Inpatient claims)
Output data: $DAW105.PDAPADPM.A1B3062I
(Associated records, category 1, set B, Inpatient claims)
Output data: $DAW105.PDAPADPM.A2A3062O
(Associated records, category 2, set A, outpatient claims)
output data: $DAW105.PDAPADPM.A2B3062O
(Associated records, category 2, set B, outpatient claims)
Output data: $DAW105.PDAPADPM.A2A3062I
(Associated records, category 2, set A, Inpatient claims)
Output data: $DAW105.PDAPADPM.A2B3062I
(Associated records, category 2, set B, Inpatient claims)
Output data: $DAW105.PDAPADPM.A3A3062O
(Associated records, category 3, set A, outpatient claims)
Output data: $DAW105.PDAPADPM.A3B3062O
(Associated records, category 3, set B, outpatient claims)
Output data: $DAW105.PDAPADPM.A3A3062I
(Associated records, category 3, set A, Inpatient claims)
Output data: $DAW105.PDAPADPM.A3B3062I
(Associated records, category 3, set B, Inpatient claims)
Output data: $DAW105.PDAPADPM.A4A3062O
(Associated records, category 4, set A, outpatient claims)
Output data: $DAW105.PDAPADPM.A4B3062O
(Associated records, category 4, set B, outpatient claims)
Output data: $DAW105.PDAPADPM.A4A3062I
(Associated records, category 4, set A, Inpatient claims)
Output data: $DAW105.PDAPADPM.A4B3062I
(Associated records, category 4, set B, Inpatient claims)
Output data: $DAW105.PDAPADPM.A5A3062O
(Associated records, category 5, set A, outpatient claims)
Output data: $DAW105.PDAPADPM.A5B3062O
(Associated records, category 5, set B, outpatient claims)
Output data: $DAW105.PDAPADPM.A5A3062I
(Associated records, category 5, set A, Inpatient claims)
Output data: $DAW105.PDAPADPM.A5B3062I
(Associated records, category 5, set B, Inpatient claims)
Output data: $DAW105.PDAPADPM.A6A3062O
(Associated records, category 6, set A, outpatient claims)
Output data: $DAW105.PDAPADPM.A6B3062O
(Associated records, category 6, set B, outpatient claims)
Output data: $DAW105.PDAPADPM.A6A3062I
(Associated records, category 6, set A, Inpatient claims)
Output data: $DAW105.PDAPADPM.A6B3062I
(Associated records, category 6, set B, Inpatient claims)
Output data: $DAW105.PDAPADPM.A7A3062O
(Associated records, category 7, set A, outpatient claims)
Output data: $DAW105.PDAPADPM.A7B3062O
(Associated records, category 7, set B, outpatient claims)
Output data: $DAW105.PDAPADPM.A7A3062I
(Associated records, category 7, set A, Inpatient claims)
Output data: $DAW105.PDAPADPM.A7B3062I
(Associated records, category 7, set B, Inpatient claims)
Output data: $DAW105.PDAPADPM.A8A3062O
(Associated records, category 8, set A, outpatient claims)
Output data: $DAW105.PDAPADPM.A8B3062O
(Associated records, category 8, set B, outpatient claims)
Output data: $DAW105.PDAPADPM.A8A3062I
(Associated records, category 8, set A, Inpatient claims)
Output data: $DAW105.PDAPADPM.A8B3062I
(Associated records, category 8, set B, Inpatient claims)

Extra steps:

Claim type 023 provider information recon:

  • Claim type 23s are no longer required to have provider information populated. On MMIS the Performing provider info was copied from the Billing provider info if it was blank. This is no longer the case. The decision was made to pull the associated claims and go back to pull the billing provider info for the CT 23s later.
  • Source: $libr01.pdapahqp.recn3062
  • Output: $daw105.pdapadpm.rec3062I (CT 23 OCNS from all associated record files)
  • Output: $daw105.pdapadpm.recn3062 (CT 23 Billing provider data)

In business objects:

  • Descriptions for Client Type program, Claim TOS code, Procedure code, DRG code, Place of Service code and diagnosis code were pulled.

In access:

  • Descriptions were joined to associated claim data and saved to an excel spreadsheet.