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PB-216 158 



S/UR Operational Techniques 



Medical Services Administration, 



prepared for 

Medical Services Administration, SRS 



APRIL 1973 



Distributed By: 




1*1*73 



PB 216 158 



S/UR OPERATIONAL TECHNIQUES 



U.S. DEPARTMENT OF HEALTH, EDUCATION AND WELFARE 
SOCIAL AND REHABILITATION SERVICE 
MEDICAL SERVICES ADMINISTRATION 
MANAGEMENT SYSTEMS DIVISION 



Washington , D.C 



February, 1973 



BIBLIOGRAPHIC DATA 
SHEET 



1. Report No. 

SRS-73-2i+708 



3. Recipient's Accession No. 



4. Title and Subtitle 



S/UR Operational Techniques 



5. Report Date 

April 1, 1973 



7. Author(s) 



Division of Management Systems 



8. Performing Organization Rept. 
No. 



9. Performing Organization Name and Address 

Medical Services Administration, SRS 
Department of Health, Education and Welfare 
330 C St. S.W. 

W a s hington, D. C . 2Q2Q1 



10. Project/Task/Work Unit No. 



11. Contract/Grant No. 



12. Sponsoring Organization Name and Address 



Same as (9) 



13. Type of Report & Period 
Covered 

Final 



14. 



15. Supplementary Notes 



16. Abstracts 



The major purpose of this publication is to assist personnel in State 
Medicaid agencies charged -with utilization review responsibilities. 
It describes the use of a retrospective exception report -based surveillance 
and utilization review (S/UR) technique. Emphasis is on making effective 
use of the reports generated by the Surveillance and Utilization Review 
Subsystem of the Medicaid Management Information System (MMIS ) . This 
effort is undertaken to safeguard the integrity of State Medicaid programs 
by determining that patterns of recipient utilization and provider practice 
are appropriate and to provide a basis for remedial action/ffnly are not. 

This volume defines specific operational techniques which allow the State- 
Title XIX agency to fully use the data generated in the S/UR subsystem 
and relate it to acceptable medical norms and experience. 



17. Key Words and Document Analysis. 17a. Descriptors 



17b. Identifiers/Open-Ended Terms 



17c. COSATI Field/Group 



18. Availability Statement 



19. Security Class (This 
Report) 

UNCLASSIFIED 



20. Security Class (This 
Page 

UNCLASSIFIED 



21. No. of Pages 

2hk 



22. Price 



FORM NTIS-35 (REV. 3-72) 



THIS FORM MAY BE REPRODUCED 



USCOMM-DC M952-P72 



ACKNOWLEDGEMENTS 



Appreciation is extended to the following individuals who 
provided invaluable assistance in the concepualization, writing and 
publication of the S/UR Operational Techniques: Dr. Alton B. Cobb, 
Mississippi; Dr. Norman J. Cole, Colorado; Robert Wessell, Illinois; 
Thomas C. Lindsay, Michigan; Thomas E. Singleton, Missouri; 
Charles F. McDermott, Oklahoma; Dr. Charles L. Tanner and John Spiegel, 
MSA, Washington, D. C. 

Special thanks go to Gray J. Arnold and William A. Flinn, Jr. of 
CG Consultants. Members of the Management Systems Division who 
provided advice and assistance were J. Patrick McCarthy, Deputy Director, 
Gerald Tolpin, James R. Cole, Joseph G. Wechsler, Francis H. Bender, 
Leroy Weisenborne, Arthur A. Pergam, Leslie S. Weinstein and 
Clara E. Stith. 



Richard 0. Godmere 
Director 

Management Systems Division 



February 1, 1973 



S/UR OPERATIONAL TECHNIQUES 
TABLE OF CONTENTS 



SECTION PAGE 

1. INTRODUCTION X 

1 . 1 PURPOSE 2 

1 . 2 METHOD 3 

1 . 3 SCOPE 3 

1.4 DEFINITION OF SURVEILLANCE AND UTILIZATION REVIEW (S/UR) 5 

1.5 OTHER FORMS OF UTILIZATION REVIEW 7 

1.6 RELATIONSHIP OF S/UR TO OTHER FORMS OF UTILIZATION 

REVIEW 7 

1.7 S/UR 1 S RELATIONSHIP TO XIX PLAN REQUIREMENTS 8 

1.7.1 UTILIZATION REVIEW OF CARE AND SERVICES 

(CFR 250.20) 9 

1.7.2 AGREEMENTS WITH PROVIDERS (CFR 250.21) 11 

1.7.3 FRAUD IN MEDICAL ASSISTANCE PROGRAM (CFR 250.80) 13 

1.7.4 FAIR HEARINGS (CFR 205.10) 13 

1.7.5 APPLICATION TO PROFESSIONAL STANDARDS REVIEW 
ORGANIZATIONS (PSRO) 13 

1.7.6 APPLICATION TO EARLY AND PERIODIC SCREENING 
DIAGNOSIS, AND TREATMENT OF ELIGIBLE INDIVIDUALS 
UNDER AGE 21 (EPSDT) l4 

2. REPORT DESCRIPTIONS 15 

2.1 REPORTING CONCEPTS ■ 16 

2.2 REPORT ABSTRACTS 18 
g.3 SUMMARY PROFILE REPORTS 21 



SECTION PAGE 

2.3.1 INTENDED USAGE 21 

2.3.2 EXCEPTION PROCESSING TECHNIQUES 21 

2.3.3 ORGANIZATION AND FORMAT 24 

2.3.4 GENERAL DESCRIPTION OF CONTENT 26 

2.3.5 INDIVIDUAL REPORT DEFINITIONS 26 

2.3.5.1 RECIPIENT 28 

2.3.5.2 PHYSICIAN SERVICES 33 

2.3.5.3 INPATIENT HOSPITAL SERVICES 42 

2.3.5.4 OUTPATIENT HOSPITAL SERVICES 48 

2.3.5.5 liONG TERM CARE FACILITY SERVICES 53 

2.3.5.6 DENTAL SERVICES 57 

2.3.5.7 PRESCRIBED DRUGS 6l 

2.3.5.8 OTHER PROVIDER SERVICES 66 

2.4 TREATMENT ANALYSIS REPORTS 

2.4.1 INTENDED USAGE 69 

2.4.2 EXCEPTION PROCESSING TECHNIQUES 69 

2.4.3 ORGANIZATION AND FORMAT 71 

2.4.4 GENERAL DESCRIPTION OF CONTENT 72 

2.4.5 INDIVIDUAL REPORT DEFINITIONS 73 

2.4.5.1 PHYSICIAN SERVICES 74 

2.4.5.2 INPATIENT HOSPITAL SERVICES 79 

2.5 MANAGEMENT SUMMARY REPORTS 84 

2.5.1 INTENDED USAGE 84 

2.5.2 ORGANIZATION AND FORMAT 84 

2.5.3 GENERAL DESCRIPTION OF CONTENT 87 

2.5.4 INDIVIDUAL REPORT DEFINITIONS 87 



SECTION 



PAGE 







2.5.^.1 


RECIPIENT CLASS PROFILES 


89 






2.5.4.2 


PHYSICIAN SERVICES CLASS 










PROFILES 


97 






2.5.4.3 


INPATIENT HOSPITAL SERVICES 










CLASS PROFILES 


106 






2.5.4.4 


OUTPATIENT HOSPITAL SERVICES 










CLASS PROFILES 


114 






2.5.4.5 


LONG TERM CARE FACILITY 










SERVICES CLASS PROFILES 


120 






2.5.4.6 


DENTAL SERVICES CLASS PROFILES 


126 






2.5.4.7 


PRESCRIBED DRUGS CLASS PROFILES 


131 






2.5.4.8 


OTHER PROVIDER SERVICES CLASS 










PROFILES 


137 






2.5.4.9 


PHYSICIAN TREATMENT ANALYSIS 










CLASS PROFILES 


141 






2.5.4.10 INPATIENT HOSPITAL TREATMENT 










ANALYSIS CLASS PROFILES 


144 


CLAIM 


DETAIL REPORTS 


147 


2.6 


.1 


INTENDED 


USAGE 


147 


2.6 


.2 


SELECTION CAPABILITIES 


147 


2.6 


.3 


ORGANIZATION AND FORMAT 


147 


2.6 


.4 


GENERAL 


DESCRIPTION OF CONTENT 


148 


2.6 


.5 


INDIVIDUAL REPORT DEFINITIONS 


148 






2.6.5.1 


RECIPIENT 


150 






2.6.5.2 


PROVIDER: PHYSICIAN SERVICES 


157 






2.6.5.3 


PROVIDER INPATIENT HOSPITAL SERVICES 


161 






2.6.5.4 


PR0VH5ER:.0UTPATIMT; ' HOSPITAL SERVICES 


165 



SECTION 

2.6.5.5 LONG TERM CARE FACILITY 

2.6.5.6 PROVIDER DENTAL SERVICES 

2.6.5.7 PROVIDER PRESCRIBED DRUGS 

2.6.5.8 OTHER PROVIDER SERVICES 
2.7 REQUESTED SPECIAL REPORTS 

2.7.1 INTENDED USAGE 

2.7.2 REPORTING CAPABILITIES 

2.7.3 ORGANIZATION AND FORMAT 

2.7.4 GENERAL DESCRIPTION OF CONTENT 

2.7.5 DATA BASE DEFINITION 

2.7.5.1 PROVIDER MASTER FILE 

2.7.5.2 MEDICAID ELIGIBILITY MASTER 
FILE 

2.7.5.3 CLAIMS HISTORY FILE 
3. AREAS OF EXCEPTIONAL UTILIZATION 

3.1 INTRODUCTION 

3.2 INDICATORS OF EXCEPTIONAL UTILIZATION 

3.2.1 RECIPIENTS 

3.2.2 PHYSICIAN SERVICES 

3.2.3 INPATIENT HOSPITAL SERVICES 

3.2.4 OUTPATIENT HOSPITAL SERVICES 

3.2.5 LONG TERM CARE FACILITY SERVICES 

3.2.6 DENTAL SERVICES 

3.2.7 PRESCRIBED DRUGS 



SECTION PAGE 

4. UTILIZATION REVIEW PROCEDURES 207 

4.1.1 ANALYSIS OF REPORTS 208 

4.1.1.1 PROCEDURE OF ANALYSIS 208 

4.1.1.2 EXAMPLES OF PROCEDURES 213 

4.1.2 INVESTIGATORY AND REMEDIAL ACTIONS 

DEFINITIONS AND REQUISITES 222 

4.1.2.1 SUFFICIENT DOCUMENTATION 222 

4.1.2.2 ESTABLISHMENT OF PRIORITIES 223 

4.1.2.3 LEGAL ADVICE 224 

4.1.2.4 SAFEGUARDS AGAINST CAPRACIOUS 

ACTION 224 

4.1.2.5 CO-OPERATIVE ATTITUDE OF THE 
PROFESSIONAL ORGANIZATIONS AND 

SOCIETIES OF THE PROVIDERS 225 

4.1.2.6 ADEQUATE STAFF AND RESOURCES 226 

4.1.2.7 PROVIDER AGREEMENTS 227 

4.1.3 INVESTIGATORY ACTIVITIES 228 

4.1.3.1 PROVIDER VISITS AND AUDITS 229 

4.1.3.2 RECIPIENT CONTACTS 229 

4.1.3.3 INFORMAL HEARINGS 230 
4.1. 3.^ MEDICARE DATA 230 

4.1.4 REMEDIAL ACTIONS 231 
4.1.4.1 LIST OF CORRECTIVE ACTIONS 232 

4.2 SYSTEM CONTROL PROCEDURES 234 

4.2.1 INTRODUCTION 234 

4.2.2 CLASS GROUP CONTROL 234 



SECTION PAGE 

4.2.3 EXCEPTION CONTROL 936 

5 . APPENDIX 238 

5.1 GLOSSARY OF TERMS 239 



1. INTRODUCTION 



-1- 



1 . INTRODUCTION 



1.1 PURPOSE 

The mahor purpose of this publication is to assist 
personnel in State Medicaid agencies charged with utilization 
review responsibilities. It describes the use of a retro- 
spective, exception report-based surveillance and utilization 
review S/UR technique. Emphasis is on making effective use 
of the reports generated by the Surveillance and Utilization 
Review Subsystem of the Medicaid Management Information Syste. 
(MMIS). This effort is undertaken to safeguard the integrity 
of State Medicaid programs by determining that patterns of reci- 
pient utilization and provider practice are appropriate and to 
provide a basis for remedial action when they are not. Proper 
use of the S/UR reports by State Agency personnel is crucial if 
the promise of the Medicaid Management Information System is to 
be fully realized and if the investment in general and detailed 
design and operational costs is to be maximized. 

Subsidiary purposes of this publication are: 

To provide a basis for technical assistance to State 
agencies implementing all or a portion of the S/UR subsystem 
or its equivalent. 

To provide instructional material for use in orientation 
and training of Regional Office and State Agency staff in the 
utilization review process. 

To elaborate on the general design of the S/UR subsystem by 
reviewing its organization, the content and format of reports, 

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and by illustrating with examples the use of selected S/UR 
reports . 

To place post-payment , exception report based utilization 
review techniques into a "broader utilization review context. 

1.2 METHOD 

This publication defines specific operational techniques 
which allow the user to exploit fully the data generated in the 
S/UR subsystem of the MMIS and relate it to acceptable medical 
care norms and experience. 

Basically these operational techniques outline how to: 

A. Use the basic S/UR reports to make judgment about the 
quantitative and qualitative adequacy of medical and 
remedial care and services provided. 

B. Increase effectiveness in detecting instances of error 
or alleged fraud. 

C. Use S/UR generated informatipm dm cpngtimct&on with 
Management and Administrative Reporting Subsystem (MARS) 
data for short and long-range planning and evaluation 
of program effectiveness. 

1.3 SCOPE 

Whereas the S/UR subsystem general design document is 
addressed to data processing personnel, this publication is 
addressed, mainly to the personnel within the State agency medi- 
cal assistance unit charged with the conduct of S/UR activity. 



-3- 



The operational techniques relate to successful imple- 
mentation of the purposes of the S/UR general design: 

A. Development s over time, of a comprehensive statistical 
profile of medical care delivery and utilization pat- 
terns established by provider and recipient partici- 
pants in the Medicaid program. 

B. Identification of potential misutilization and possible 
procedures for corrective actions. 

C. Provision for the production and use of information 
which will reveal, and facilitate investigation of 
potential defeets in the level of care or quality of 
service provided under Medicaid. 

B, Accomplishment of the substantive objective stated 
above with a minimum level of manual clerical effort 
end with a maximum level of flexibility with respect 
to management objectives. 

The individual operational techniques as discussed in this 

publication: 

A. Illustrate the organization, content and format of 
the S/UR reports and discuss procedures for their 
effective analysis, including investigating activities 
and remedial actions. 

B. Indicate that understanding of this approach to the 
utilization review process will assist in making de- 
cisions regarding the organization and staffing of the 

-4- 



State agency utilization review functions. 

C. Define areas of misutilizat ion and indicators of mis- 
utilization and the establishment of priorities among 
them. 

D. Explain the tailoring of reports to individual user 
needs emphasizing selection of report elements, ex- 
ception levels , and classification choices. 

1.4 DEFINITION OF SURVEILLANCE AND UTILIZATION REVIEW (S/UR) 

S/UR is an extremely flexible and powerful management 
tool for State Medicaid directors that will help identify pat- 
terns of inappropriate care and services. It is concerned with 
both the quantitative and qualitative aspects of medical services 
purchased by Medicaid. Revealed in substantial detail is actual 
Medicaid experience including norms, frequency distributions, 
trends, and comparisons among time periods which permits sur- 
veillance of the program. Also revealed are situations which 
depart from the norms, and the detailed information necessary 
for utilization review. 

Acceptable norms are established from accumulated data 
with assistance of professional groups and statistical manipu- 
lation. The norms are basic to an exception reporting capability 
identifying providers and recipients who show excessively high 
or low patterns of practice or utilization. Thus participants 
in the program are easily compared with others of their class. 
Further, the technique uses specific and general indicators to 



-5- 



concentrate on previously determined common areas of mis-utili- 
zation. With this exception - reporting procedure and identi- 
fied areas of frequent program misutilization, the State adminis- 
trator can readily direct his staff's attention to correcting 
inappropriate use of the Medicaid program. 

S/QR is a computer-based subsystem of the MMIS. The sub- 
system derives most of its data from paid claims; consequently,, 
the emphasis is on a retrospective review covering both reci- 
pients and providers of service. It operates on an exception- 
reporting basis. This subsystem by itself will not stop mis- 
utilization by either providers or recipients but it will give 
administrators information they need to initiate appropriate 
remedial action. 

After careful analysis of all computer-generated informatic 
the State agency staff can initiate contact with the providers 
and recipients for additional data as necessary. Instances of 
exceptional utilization not easily resolved on the basis of in- 
formal contacts between agency professional staff and the provider 
may be referred to professional peer review groups for appro- 
priate action. Instances of exceptional utilization by reci- 
pients may require follow-up by Agency social service staff with 
remedial actions determined jointly between social services and 
Medicaid staff. S/UR should not be confused with the totality 
of utilization review activities; it is retrospective,, dependent 
on the claims payment process and operates on an exception re- 
port basis. 

-6- 



1.5 OTHER FORMS OF UTILIZATION REVIEW 

There are other utilization review activities which can 
"be classified as prospective either to delivery of the service 
or to payment for it. Prior authorization, for instance, 
usually means review "before rendering the service to determine 
medical necessity; it is combined sometimes with a fiscal review 
to determine the availability of funds to pay for the service. 
Utilization review may be incorporated into the claims payment 
process. It covers the universe of services as to their medi ,1 
necessity and the reasonableness of the amount charged with 
payment being delayed until any questions in either area are 
cleared. Concurrent utilization review includes activities by 
institution-based utilization review committees and periodic 
medical review of nursing home care. It is apparent that pro- 
spective, concurrent and retrospective utilization review techni- 
ques should be combined into an integrated, reenforcing effort. 

The three types of UR discussed above each have their 
place of relative importance depending on the category of service 
being reviewed. 

1.6 RELATIONSHIP OF S/UR TO OTHER FORMS OF UTILIZATION REVIEW 

For physician services an emphasis on retrospective re- 
view of patterns of care, rather than a prospective review of 
each physician encounter, is much more efficient and effective. 
For inpatient hospital care a prospective review of each admission 



-7- 



based on length-of-stay and diagnosis combined with a retrospec- 
tive review of each hospital's overall pattern of patient care 
will indicate areas of exceptional utilization. To review in- 
patient eare on just a prospective basis will not identify 
situations where providers repeatedly maximize (or minimize) the 
allowable lengths of stay. Review of care on a retrospective 
basis will identify unusual lengths of stay Hased on diagnosis , 
but the problem is identified after payment to the institution 
has been made and can present problems with adjustments and 
collections. However, regardless of the type of medical care 
or the type of UR technique , a summarization of the total 
experience and its subsequent analysis is needed in order to 
effectively control the Medicaid Program. Such a summarization 
is possible only through the S/UR Subsystem of the MMIS, or its 
equivalent. 

S/UR provides a comprehensive and orderly way of collect- 
ing and processing information allowing a precise audit trail 
which guarantees the public accountability of the taxpayers' 
monies; it specifies who ggot lato&t, services, when, why these ser- 
vices were rendered or received, where performed and how much 
they cost. With the resulting accurate, consistant and timely 
reports, the State agency (and subsequently the Federal govern- 
ment) will be exercising reasonable program control of Medicaid. 
While S/QR is but one of several approaches to the review of 
utilization of Medicaid services, it is primary and crucial. 

1.7 S/UR'S RELATIONSHIP TO XIX PLAN REQUIREMENTS 

A basic requirement levied on the States under the Title 

XIX Legislation is the need for a State plan in which the State 

-8- 



outlines the specifics of its Medicaid coverage, recipients 
and services. Outlined "below are those State plan requirements 
which relate to utilization review. Foremost, of course is 
utilization review of care and services (CFR 250.20). Also 
related are requirements for agreements with providers (CFR 
250.21), periodic medical review and medical inspections in 
skilled nursing homes and mental hospitals (CFR 250.23), fraud 
in the medical assistance program (CFR 250. 80), and fair hear- 
ings (CFR 250.10). 

This publication is neither a Program Regulation nor a 
Program Regulation Guide and does not have the force or effect 
of such documents. Rather, it is an operational technique to 
be used at the discretion of the State agency to maximize the 
effectiveness of the reports generated by the s/UR Subsystem of 
the MMIS. However, in any discussion of a system of utilization 
review in Medicaid, the relationship between mandated require- 
ments and procedures for compliance should he outlined. The 
following section indicates the extent to which properly im- 
plemented S/UR operational techniques meet completely or partially 
the State plan requirement identified. 

1.7.1 Utilization Review of Care and Services (CFR 250.20) 

For items other than inpatient hospital care and 
long term care facilities, S/UR may be the primary pro- 
cess. For inpatient hospital and extended care facilities 
it is secondary to the utilization review committee 



activity required "by Medicare and Medicaid, for skilled 
nursing homes and mental hospitals it is secondary to the 
requirements for periodic medical review and medical in- 
spections. S/UR using the exception reports can fulfill 
those portions of the utilization review of care and 
services requirements calling for: 1) a post audit pro- 
cedure able to address patterns of care in the context 
of medical necessity and appropriateness and over-all 
utilization within an institution, a service area, or a 
provider's Medicaid workload; 2) procedures "based on a 
statistically significant sample or other reasonable basis 
of pertinent data; and 3) subsequent review of services 
which also require review prior to or concurrent with pay- 
ment . 

For hospital services the S/UR reports are a means 
to determine the effectiveness of hospital-based utili- 
zation review committees. The S/1JR reports provide an 
instrument to measure changes in utilization within in- 
dividual hospitals and to make comparisons among hospitals 
with like characteristics. Likewise the S/UR reports may 
be used for these same purposes with respect to programs 
which certify in advance the length of stay which will be 
allowed at the time a recipient is admitted. Where such 
pre-certification programs have not been implemented, and 
the hospital based utilization review committees are 
thought to be functioning ineffectively for Medicaid re- 



-10- 



cipients, S/UR may "be the major process for utilization 
review of inpatient hospital care. 

For long term care 3 S/UR provides strong support 
for the medical review and periodic inspection process 
by providing for routine collection and reporting of data 
essential to effective medical review. This same type 
of data may also "be used during the intervals between 
medical reviews and periodic inspections for utilization 
review purposes , to point out the patterns of use of medi- 
cal care by residents of long term care facilities, and 
to provide an indication of the effectiveness of the 
medical review and periodic inspection process. 

For non- institutional medical services, especially 
high volume, low cost ones, properly analyzed S/UR reports 
with appropriate follow-up investigation will meet in 
full State plan requirements for utilization review of care 
and services. 

1.7.2 Agreements with Providers (CFR 250.21) 

Agreements with providers require them to keep 
records to disclose the extent of services provided to 
Medicaid recipients and to furnish information regarding 
payments claimed on the request of the State Agency. 
This plan requirement thus provides authority for the 
utilization review staff to obtain information beyond that 
available from S/UR which aids in the determination of 



-11- 



whether the exceptional situation identified by the S/UR 
reports is truly abusive, requiring remedial action. 

1.7.3 Fraud in Medical Assistance Program (CFR 250. 80) 

For the fraud requirement, S/CJR is a means to 
establish and maintain methods and criteria for identi- 
fying situations in which a question of fraud in the pro- 
gram may exist. In addition, it can provide for establish- 
ing a basis for verifying with recipients whether services 
billed by providers were actually received. 

1.7.4- Fair Hearings (CFR 205.10) 

Portions of the Fair Hearing Policy relate to utili- 
zation review decisions. This relationship has been clari- 
fied in MSA Field Staff Information and Instruction Series 
#42 which indicates when fair hearing requirements for 
advance notice and continuation of assistance apply to 
agency decisions an utilization. 

1.7.5 Application to Professional Standards Review Organizations 

(PSRO) 

Enactment of P.L. 92-603 calls for the development 
of Professional Standards Review Organization. Such 
organizations will address themselves to inpatient hospital 
care and may extend their activities to all categories 
of care purchased by Medicaid. For inpatient hospital care 
«tere PSROs may rely heavily on in-house utilization re- 
view committee activities, S/UR reports can make a major 



-12- 



contribution to successful PSRO actions by providing 
a "basis for the establishment of State and program 
specific utilization norms and criteria as well as by 
facilitating comparisons among hospitals and in general, 
providing a tool to measure the effectiveness of PSRO 
activity. 

When the PSRO is concerned with other categories 
of care, S/UR reports - with instances of exceptional 
utilization identified - could be presented to its staff 
for analysis, further investigation, and corrective or 
remedial actions as necessary. 

Should the PSRO prefer a prepayment review, a "Model 
Treatment Plan" module could be added to the claims pro- 
cessing subsystem. If that is done, the past payment 
S/UR reports should be used to establish norms and to 
measure the effectiveness of the "Model Treatment Plan" 
approach to utilization review. 

For maximum usefulness to a PSRO, the S/UR subsystem 
should be modified to include all medical care for persons 
past 65 years of age, rather than only that paid exclusive 
ly by Medicaid. 

1.7.6 Application to Early and Periodic Screening Diagnosis, 

and Treatment of Eligible Individuals Under Age 21 (EPSDT) 

Requisite to successful application of the S/UR 
subsystem to EPSDT is development of a method to identify 

-13- 



and code the various screening services. Once this is 
accomplished, the S/QR reports discussed under subsequent 
headings can he adapted to furnish EPSDT information. 
For example , the Summary Profile, Management Summary, and 
Claims Detail Reports provide information on the medical 
and remedial care and services (treatment) furnished re- 
cipients who have been screened. Information is organized 
both for recipients and providers. In addition the Treat- 
ment Profile Summary Reports can be used to assess, by 
diagnostic categories of special interest to EPSDT officials, 
physicians and inpatient hospital services. The Requested 
Special Report capability of the S/UR subsystem is also 
of value since it is sufficiently flexible to be used in 
complying with EPSDT Federal Reporting Requirements. 

In adapting the S/UR subsystem to meet EPSDT needs, 
another desirable addition to the MMIS is collection and 
entry into the System of flfeta on the referrals which re- 
sult from screening activities. Unless this is done the 
information on the medical care furnished to recipients of 
screening services will not reveal the tie-in between 
screening and subsequent diagnosis and treatment. Any cause 
and effect relationship would have to be assumed rather than 
known more precisely. 



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REPORT DESCRIPTIONS 



-15- 



2. REPORT DESCRIPTIONS 



2.1 REPORTING CONCEPTS 

In order to successfully control utilization of the 
Medicaid Program by its individual participants (providers 
and recipients) it is first necessary to discover specific 
cases of exceptional utilization. The primary input to this 
discovery process must be meaningful and relevant information. 
It is to assist in satisfying this need for information that 
all major reports produced by the Surveillance and Utilization 
Review Subsystem have been designed. The following discussion 
is intended to present the concepts underlying major S/UR re- 
ports according to the methods by which their information con- 
tent is collected, organized and analyzed, 

The major concept underlying the information collection 
method requires that it produce consistent, orderly and 
accurate results and, at the same time, place a minimum addi- 
tional burden on limited human resources. Information col- 
lection also must be continuous over time, reflecting the 
dynamic nature of health care delivery and acquisition pat- 
terns. These requirements have limited the basic information 
content of all S/UR reports to that which may be collected on 
a continuing basis as a by-product of the routine administra- 
tive procedures of provider and recipient enrollment and, 
primarily, of claim adjudication. 

Before collected information can be of any value it must 
be organized in a manner which allows meaningful analysis and 
is amenable to human comprehension. Organization of Medicaid 
utilization information is conceptually useful on a per claim, 
per spell of illness, and per participant basis. Since the 
S/UR subsystem is retrospective in nature and, therefore, 
is concerned with overall patterns of utilization, S/UR reports 
present information organized on a participant basis. Subse- 
quent portions of this chapter will discuss specific details 
of per participant organization of information as employed by 



the S/UR Subsystem. However, the basic concept behind this 
organization requires that it be concise and subject to direct 
analysis . 

Once information has been collected and organized, a 
method of analysis must be applied in order to discover spe- 
cific cases of exceptional utilization. The primary constraint 
governing the methods of analysis available to the S/UR Subsystem 
is the extremely large volume of information which must be taken 
into consideration. The millions of claims, thousands of pro- 
viders, and hundreds of thousands of recipients which must 
be subjected to analysis create a situation which demands an 
automated technique in order that analysis may be timely and 
cost justified. Since detailed, automated analysis and evalu- 
ation of health care rendered is no more possible at the 
present than is automated diagnosis and selection of treatment, 
a summary level exception reporting logic has been devised 
for use in the production of S/UR reports. This method of 
analysis gives consideration to a number of general statistical 
indicators which have been designed to reveal potential cases 
of exceptional utilization. The numerical values of statistical 
indicators developed for each individual participant are evalu- 
ated against a predetermined range of acceptable numerical 
values. Only those participants whose statistical indicators 
have fallen outside the acceptable range of values are reported 
out of the analysis process. 

From this point on, the process of discovering exceptional 
utilization requires human analysis, employing in most cases, 
sound medical judgement. However, the automated analysis will 
function as an effective screening mechanism, reducing the 
volume of information which must be considered by people down 
to a realistic, manageable level. Furthermore, all information 
collected and organized by the automated procedure is made 
readily available to the human analyst in a format conducive 
to effective use. 



-17- 



2.2 REPORT ABSTRACTS 



Reporting concepts discussed in the preceding section 
of this chapter have been implemented by the S/UR Subsystem 
through the vehicle of four major sets of routine reports 
together with a special reporting capability. Following 
sections of this chapter will provide a detailed description 
of each of these sets of reports. However, for purposes of 
orientation, this section provides a brief abstract of each 
set . 

Summary Profile Reports are the primary tool 
provided by the S/UR Subsystem for the detection 
of potential exceptional utilization of the 
Medicaid Program. These reports present, for each 
individual Medicaid participant, an interrelated 
set of statistical indicators which have been 
carefully selected to reveal those known types of 
exceptional utilization which are subject to 
detection by statistical exception reporting 
techniques. Information contained in these reports 
is subjected to automated analysis so that only 
those participants who present a strong probability 
of requiring investigation for exceptional utili- 
zation are reported. 

The basic format is the same for all Summary 
Profile Reports. However, information content 
(statistical indicators) varies between providers 
and recipients and, for providers, according to 
Category of Service. All information presented 
is summarized at the participant level from 
detailed data contained in adjudicated claims, 
and consists of various unduplicated counts, 
service counts, and dollar accumulations together 
with appropriate ratios, averages, and percents 
computed therefrom. 



Treatment Analysis Reports are available to facil- 
itate, to the extent possible, an analysis of the 
level and quality of care rendered by individual 
providers of physician and inpatient hospital ser- 
vices. These reports present, for each individual 
provider, an itemization of services rendered 
according to each primary diagnosis reported. In- 
formation contained in these reports is subjected 
to automated analysis so that only those providers 
who show diagnosis- treatment interrelationships 
which deviate significantly from a predetermined 
norm are reported for further investigation. 
Treatment Analysis Reports may also be requested 
for specific providers in order to support the 

investigation of exceptional utilization indicated 
by Summary Profile Reports. 

Management Summary Reports are provided to support 
the analysis process employed in the production of 
Summary Profile Reports and Treatment Analysis 
Reports. This analysis process requires the devel- 
opment of norms of care against which each individ- 
ual participant may be evaluated. Norms are devel- 
oped by classifying participants into peer groups, 
computing an average and standard deviation on each 
statistical indicator by peer group, and then 
establishing a "normal" range of indicator values 
as the average of each indicator plus and minus a 
predetermined number of standard deviations from 
the average. Each statistical indicator within 
each Summary Profile Report and each Treatment 
Analysis Report will have a norm, or range of accept- 
able values, developed for it automatically in this 
fashion. In recognition of the fact that this method 
will not always produce valid results, the basic sta- 
tistics from which the norms are computed are printed 



-19- 



out in Management Summary Reports to f acilitatexm&n- 
ual adjustment of the automatically determined norms. 

The basis format of each Management Summary 
Report is the same as that of its corresponding- 
Summary Profile or Treatment Analysis Report, 
However, the content of the former reports applies 
to peer groups of individual participants whereas 
the content of the latter reports applies to an 
individual participant. 

• Claim Detail Reports are available on a request basis 
to support the investigation of exceptional utiliza- 
tion by individual Medicaid participants as indi- 
cated by Summary Profile and Treatment Analysis 
Reports. These reports present, for user speci- 
fied participants, a listing of essential data 
from each claim paid with a date of service within 
a fifteen month time period. For each participant, 
selectivity of claim detail printed may be exer- 
cised according to dates of service, procedure 
code, drug code, diagnosis code and category of 
service . 

o Special Reports may be requested from the S/UR 
Subsystem in order to satisfy requirements for 
certain information which is obtainable from paid 
claims but is not covered by standard reports. In 
order to request special reports the user must 
specify what information is to be selected and in 
what format it is to be printed. In effect the 
system selects paid claims, extracts data there- 
from, does arithmetic on extracted data, and then 
prints the final results all under control of user 
specified parameters but within reasonable con- 
straints of complexity. 



-20- 



2.3 SUMMARY PROFILE REPORTS 



2.3.1 Intended Usage 

Summary Profile Reports have been designed to 
provide a summary picture, covering a fifteen month 
time period, of the utilization patterns of individ- 
ual Medicaid providers and recipients. Items of 
information contained in these reports have been 
selected, by Category of Service, to reveal common 
types of exceptional utilization subject to detection 
by statistical reporting techniques. These reports 
are intended to be used as a preliminary screening 
mechanism in order to isolate from the many thousands 
of providers and recipients those few who appear to 
be exceptional utilizers of the Medicaid program and 
to indicate for those few suspected exceptional 
utilizers the specific areas of exception utilization 
which appear to require further investigation. 

2.3.2 Exception Processing Techniques 

The screening function of Summary Profile Reports 
is implemented through an automated exception process- 
ing technique. Conceptually, the exception processing 
technique requires six major steps on the part of the 
computer system. First, a statistical profile is 
developed from information contained in paid claims 
for each individual provider and recipient. Each pro- 
file will consist of a number of statistical indica- 
tors relating to services rendered or received and the 
cost of those services. 

Second, the statistical profiles of all providers 
and recipients are classified into groups of their 
peers. These groups are called Class Groups within 



-21- 



the context of the S/UR Subsystem. There may be up 
to 100 Class Groups of recipients and up to 50 Class 
Groups for each Category of Service of providers. For 
any given run of the system, a recipient may fall into 
only one Class Group, and a provider may fall into 
only one Class Group for each Category of Service 
which he is authorized to provide. 

Third, averages and standard deviations are com- 
puted by Class Group for each indicator contained 
within each statistical profile. Only those indica- 
tors which are not. zero, meaning that a provider or 
recipient was active in the area indicated, are taken 
into consideration for these computations. A facility 
is also provided to obtain, on request, a frequency 
distribution, of any statistical indicator for any 
Class Group. 

Fourth, the averages and standard deviations 
computed in step three are used to establish norms, 
or exception criteria by Class Group for each indica- 
tor in the statistical profile. Exception criteria 
for any statistical indicator will consist of an 
upper and a lower limit. £he upper limit will consist 
of the average plus a predetermined number of standard 
deviations. The lower limit may be set to either zero 
or to the average minus a predetermined number of 
standard deviations. Since exception criteria computed 
in this manner can onlyiyield approximate results, a 
facility is provided for the manual adjustment of these 
criteria by the user. 

Fifth, the statistical profiles of all individual 
providers or recipients within eaeh Class Group are 
evaluated, indicator by indicator, against the match- 
ing exception criteria established for each Class 
Group. This evaluation process consists of comparing 



-22- 



each indicator of each individual profile against both 
the upper and lower limits. of thfe matching exception 
criteria. If an indicator falls outside the estab- 
lished range of exception criteria values then an 
exception is noted. In order to limit the volume of 
this exception processing, a facility is provided to 
consider for exception only those providers or recip- 
ients who have surpassed a predetermined volume of 
activity. 

Sixth, all providers or recipients for whom at 
least one exception was noted during step five are 
printed out for manual review. The indicator or indi- 
cators which caused the exception are flagged on the 
printed report to facilitate the investigation pro- 
cess. At this point, the Medicaid activity of each 
individual provider and recipient has been evaluated 
against the mean activity of a group of his peers and 
is presented for further investigation only if an un- 
usual deviation from that mean is noted. 

The validity of this technique of exception pro- 
cessing depends completely upon the validity of the 
statistical indicators chosen to serve as a basis for 
comparison. It is felt that, particularly for pro- 
viders, indicators which interrelate various aspects 
of Medicaid activity will produce much more meaningful 
results than will indicators which merely measure 
volume of activity. Volume oriented indicators are 
applicable only as their values approach or exceed 
practical limitations on the capability of a given 
provider to deliver quality medical care or the real- 
istic medical care requirements of a given recipient. 



2.3.3 Organization and Format 



The major element of Summary Profile Report 
organization consists of a distinction between provi- 
. der profiles and recipient profiles. Individual pro- 
vider profiles are organized into groupings first by 
Category of Service and, second by Class Group, within 
Category of Service. Within a Class Group, individual 
provider profiles may be organized into sequence 
according to one of a number of different data elements. 
Examples of data elements which may be selected by the 
user to control this final sequence are: Provider 
Number, Total Dollars Paid, and Provider Specialty 
Code . 

Individual recipient profiles are organized into 
sequence first by Class Group. As is the case with 
provider reports, individual recipient reports may be 
organized into sequence, within each Class Group, accord- 
ing to one of a number of different data elements. 
Examples of data elements which may be selected by the 
user to control the final sequ&nea of recipient re- 
ports are: Recipient Number, County Code, Social 
Worker Code, and Total Dollars Paid. 

For each individual provider or recipient whose 
profile is excepted through computer processing, one 
or more pages of statistical indicators are printed in 
the Summary Profile Report. Each such individual pro- 
vider or recipient profile is initiated with a series 
of identification and demographic data elements organ- 
ized into an Identification Section of the report. 
Following the Identification Section will appear a 
series of statistical indicators organized into a 
. matrix format. Each statistical indicator occupies 
one line or row of the matrix. Each row consists of a 



-24- 



reference number and abbreviated title for its indicator 
followed by a series of numerical values which have been 
summarized and computed from data contained in paid 
claims. Each of these values represents activity for 
one specific time period. For providers eight time 
periods are represented on the report. The first time 
period covers data from claims paid in the current month 
regardless of date of service. The second time period 
represents an average of data for a monthly period from 
paid claims with a date of service within the past 
fifteen months. The third through the seventh time 
periods cover data from paid claims with a date of ser- 
vice during the current quarter of the current year, the 
comparable current quarter from the last year, one quar- 
ter ago, two quarters ago, and three quarters ago re- 
spectively. The eighth time period represents a normal- 
ized secular trend rate covering activity represented by' 
the five preceeding time periods. The trend rate is 
computed by the following formula: 



Trend = 



-2Q 5 -Q 4 +Q 2 +2Q 1 
2 CQ-l +Q 2 + Q 3 + Q 4 +Q 6 ) 



x 100, 



where Q-^ represents the value of the most current quar- 
ter and Q2 through represent successively older quar 
ters prior to the most current quarter. 

For recipients, only six of the eight time periods 
described above are presented in the profile. Since 
recipient reports are produced quarterly, whereas pro- 
vider reports are produced monthly, and individual 
recipient Medicaid activity follows no discernible 
trend, the first and last time time periods described 
above are omitted. 



-25- 



2.3.4 General Description of Content 



As mentioned under the preceeding discussion of 
organization and format, each individual provider or 
recipient profile printed in a Summary Profile Report 
consists of a set of identification and demographic 
data elements followed by a series of statistical 
indicators or report items organized into a matrix 
format. While the basic report format remains the 
same for all Summary Profile Reports the actual content 
of identification data and statistical report items 
varies between providers and recipients, and, for pro- 
viders according to Category of Service. This varia- 
tion in content is necessary to accurately describe the 
variations in Medicaid activity between recipients and 
different types of providers. 

In the individual examples and report content 
definitions to follow, two sections of statistical 
report items are defined. The first of these sections 
contains volume oriented report items only. The second 
section contains report items which have been selected 
as specific or general indicators of various areas of 
misutilization defined for recipients and various pro- 
vider Categories of Service. A third section contain- 
ing profile type report items may be added at user dis- 
cretion. This third section would serve to fill out 
the picture of a given provider or recipient with 
report items which indicate areas of Medicaid activity 
which are less likely to be subject to exceptional 
utilization . 

2.3.5 Individual Report Definitions 

The following pages contain a Report Format Example 



-26- 



and a Report Content Definition for each of the eight 
possible variations of Summary Profile Reports. Where 
Report Format Examples containing actual report item 
values have been included, an effort has been made to 
use realistic values, representative of a typical Medi- 
caid Program. However, the intent of these examples is 
only to illustrate what a Summary Profile Report might 
look like in actual production, and not to predict 
actual utilization patterns in a specific State Medicaid 
environment . 

Report Content Definitions are keyed back to Report 
Format Examples by use of Reference Titles in the case 
of Identification Report Items, and Reference Numbers in 
the case of Profile Report Items. 



-27- 



2.3.5.1 SUMMARY PROFILE REPORT: RECIPIENT 

REPORT FORMAT EXAMPLE 
(On following page) 



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-29- 



















2.3.5.1 SUMMARY PROFILE REPORT; RECIPIENT 



REPORT CONTENT DEFINITION 
IDENTIFICATION REPORT ITEMS 

Reference Title Report Item Title 

NAME RECIPIENT NAME 

NUMBER RECIPIENT IDENTIFICATION NUMBER 

LOCATION RECIPIENT COUNTY CODE 

BIRTHDATE RECIPIENT DATE OF BIRTH 

RACE RECIPIENT RACE CODE 

SEX RECIPIENT SEX CODE 

AID CATEGORY RECIPIENT AID CATEGORY 

MONEY PAYMENT MONEY PAYMENT CODE 

THIRD PARTY LIABILITY THIRD PARTY LIABILITY CODE 

PROFILE REPORT ITEMS 

Reference Number Report Item Title and Description 

01 VOLUME SUMMARY SECTION 

01.01 DOLLARS PAID MEDICAID - Total dollars 

paid for services rendered under Title 
XIX. 

01.02 DOLLARS PAID MEDICARE - Total dollars 

paid by Title XIX for services rendered 
with primary coverage under Title XVIII 
(coinsurance and deductible) . 

01.03 TOTAL DOLLARS PAID - Total dollars paid 

by Title XIX. 

02 ESSENTIAL REPORT ITEM SECTION - All 

report items in this section refer to 
services rendered with primary coverage 
under Title XIX. 



■30- 



2.3.5.1 SUMMARY PROFILE REPORT; RECIPIENT 
REPORT CONTENT DEFINITION jk 
PROFILE REPORT ITEMS (Continued) 

Reference Number Report Item Title and Description 

02.01 NUMBER OF DIFFERENT PRIMARY DIAGNOSES - 

An unduplicated count of primary diag- 
nosis codes reported on Medicaid claims 

02.02 NUMBER OF DIFFERENT PHYSICIANS - An 

unduplicated count of individual physi- 
cians, physician groups, or physician 
clinics seen. 

02.03 NUMBER OF MEDICAL VISITS - Total number 

of all visits to physicians. 

02.04 PERCENT INITIAL VISITS - Percentage of 

all visits which were classified as 
initial . 

02.05 NUMBER OF DRUG PRESCRIPTIONS - Total 

number of drug prescriptions filled. 

02.06 PERCENT REFILL PRESCRIPTIONS - Percent- 
age of all drug prescriptions filled 
which were classified as refills. 

02.07 NUMBER OF ADDICTIVE DRUG PRESCRIPTIONS 

Total number of addictive drug pre- 
scriptions received. 

02.08 NUMBER OF DIFFERENT DRUGS - An undupli- 
cated count of individual drugs re- 
ceived. 

" 02.09 NUMBER OF PROSTHETICS AND EYEGLASSES - 

Total number of prosthetic devices and 
eyeglasses received. 



-31- 



2.3.5.1 SUMMARY PROFILE REPORT: RECIPIENT 
REPORT CONTENT DEFINITION 
PROFILE REPORT ITEMS (Continued) 

Reference Number Report Item Title and Description 

02.10 NUMBER OF DENTAL SERVICES - Total number 

of dental services received. 

02.11 NUMBER OF DENTAL EMERGENCIES - Total 

number of dental services received on 
an emergency basis. 

02.12 RATIO OF DENTAL EMERGENCIES TO SERVICES ■ 

The ratio of the number of dental emer- 
gencies to the number of dental services 

received . 

02.13 NUMBER OF TRANSPORTATION SERVICES - 

Total number of transportation services 

received . 

02.14 NUMBER OF OPTOMETRIC SERVICES - Total 

number of optometric services received. 

02.15 NUMBER OF PODIATRIC SERVICES - Total 

number of podiatric services received. 

02.16 NUMBER OF DAYS IN HOSPITALS - Total 

number of days spent as a hospital 
inpatient . 

02.17 NUMBER OF DAYS IN LONG TERM CARE 

FACILITIES - Total number of days spent 
in long term care facilities. 



-32- 



2.3.5.2 SUMMARY PROFILE REPORT: PHYSICIAN SERVICES 

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-33- 



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-34- 



2.3.5.2 SUMMARY PROFILE REPORT: PHYSICIAN SERVICES 



REPORT CONTENT DEFINITION * 
IDENTIFICATION REPORT ITEMS 



Reference Title 

NAME 

NUMBER 

LOCATION 

TYPE 

SPECIALTY 
SIZE 



Report Item Title 



PROVIDER NAME 

PROVIDER NUMBER 

PROVIDER COUNTY CODE 

PROVIDER TYPE CODE 

PROVIDER MEDICAL SPECIALTY CODE 

NUMBER OF PHYSICIANS IN GROUP 



PROFILE REPORT ITEMS 

Reference Number Report Item Title and Description 

01 VOLUME SUMMARY SECTION 

01.01 TOTAL DOLLARS PAID - Total dollars paid 

by Title XIX. 

01.02 DOLLARS PAID - MEDICAID - Total dollars 

paid for services rendered under Title 
XIX. 

01.03 DOLLARS PAID - MEDICARE - Total dollars 

paid by Title XIX for services rendered 
with primary coverage under Title XVIII 
(coinsurance and deductible). 

01.04 RECIPIENTS SERVED - TOTAL - An undupli- 

cated count of all individual recipients 
served. 

01.05 RECIPIENTS SERVED - MEDICAID * An undu- 

plicated count of individual recipients 
served with primary coverage under Title 
XIX. 



2.3.5.2 SUMMARY PROFILE REPORT : PHYSICIAN SERVICES 



REPORT CONTENT DEFINITION 
PROFILE REPORT ITEMS (Continued) 

Reference Number Report Item Title and Description 

01.06 RECIPIENTS SERVED - MEDICARE— An undu> 

plicated counts of individual recipients 
served who were eligible under Title XIX 
but had primary coverage under Title 

XVIII. 

02 ESSENTIAL REPORT ITEM SECTION - All 

Report Items in this section refer to 
services rendered to recipients with 
primary coverage under Title XIX. 

02.01 AVERAGE NUMBER OF OFFICE VISITS PER 

RECIPIENT - The ratio of the total num- 
ber of office visits to the number of 
individual recipients (unduplicated 
count) with office visits. 

02.02 AVERAGE NUMBER OF HOME VISITS PER 

RECIPIENT - The ratio of the total num- 
ber of home visits to the number of 
individual recipients (unduplicated 
count) with home visits. 

02.03 AVERAGE NUMBER OF INPATIENT HOSPITAL 

VISITS PER RECIPIENT - The ratio of the 
total number of inpatient hospital 
visits to the number of individual 
recipients (unduplicated count) with 
inpatient hospital visits. 



-36- 



2.3.5.2 SUMMARY PROFILE REPORT: PHYSICIAN SERVICES 
REPORT CONTENT DEFINITION 
PROFILE REPORT ITEMS (Continued) 

Reference Number Report Item Title and Description 

02.04 AVERAGE NUMBER OF LTCF VISITS PER 

RECIPIENT - The ratio of the total number 
of long term care facility visits to the 
number of individual recipients (undupli- 
cated count) with long term care facility 
visits . 

02.05 AVERAGE NUMBER OF OUTPATIENT HOSPITAL 

VISITS PER RECIPIENT - The ratio of the 
total number of outpatient hospital 
visits to the number of individual 
recipients (unduplicated count) with 
outpatient hospital visits. 

02.06 RATIO OF OFFICE INJECTIONS TO OFFICE 

VISITS - The ratio of the total number 
of office injections to the total number 
of office visits. 

02.07 RATIO OF INJECTIONS TO RECIPIENTS - The 

ratio of the total number of injections 
to the number of individual recipients 
(unduplicated count) served. 

02.08 RATIO OF INPATIENT HOSPITAL VISITS TO 

DAYS STAY - The ratio of the total num- 
ber of inpatient hospital visits to the 
total days stay in inpatient hospitals. 

02.09 RATIO OF LTCF VISITS TO DAYS STAY - The 

ratio of the total number of long term 
care facility visits to the total days 
stay in long term care facilities. 



-37- 



2.3.5.2 SUMMARY PROFILE REPORT: PHYSICIAN SERVICES 
REPORT CONTENT DEFINITION 
PROFILE REPORT ITEMS (Continued) 

Reference Number Report Item Title and Description 

02.10 RATIO OF SURGICAL PROCEDURES TO RECIP- 
IENTS - The ratio of the total number of 
surgical procedures to the number of 
individual recipients (undupl icated 
count) served. 

02.11 RATIO OF DIAGNOSTIC RADIOLOGY PROCEDURES 

TO VISITS - The ratio of the total num- 
ber of diagnostic radiology procedures 
to the total number of visits, 

02.12 RATIO OF DIAGNOSTIC RADIOLOGY PROCEDURES 

TO RECIPIENTS - The ratio of the total 
number of diagnostic radiology proce- 
dures to the number of individual recip- 
ients (unduplicated count) served. 

02.13 RATIO OF LABORATORY PROCEDURES TO VISITS 

The ratio of the total number of labora- 
tory procedures to the total number of 
visits . 

02.14 RATIO OF LABORATORY PROCEDURES TO 

RECIPIENTS - The ratio of the total num- 
ber of laboratory procedures to the num- 
ber of individual recipients (undupli- 
cated count) served. 

02.15 RATIO OF OTHER DIAGNOSTIC PROCEDURES TO 

VISITS - The ratio of the total number 
of other specific diagnostic procedures 
to the total number of visits. 



-38- 



2.3.5.2 SUMMARY PROFILE REPORT: PHYSICIAN SERVICES 
REPORT CONTENT DEFINITION 
PROFILE REPORT ITEMS (Continued) 

Reference Number Report Item Title and Description 

02.16 RATIO OF OTHER DIAGNOSTIC PROCEDURES TO 

RECIPIENTS - The ratio of the total num- 
ber of other specific diagnostic proce- 
dures to the number of individual recip- 
ients (unduplicated count) served. 

02.17 RATIO OF OTHER PHYSICIANS' SERVICES TO 

RECIPIENTS - The ratio of the total num- 
ber of services rendered by other physi- 
cians on referral to the number of 
individual recipients (unduplicated 
count) served. 

02.18 RATIO OF OTHER PHYSICIAN REFERRALS TO 

RECIPIENTS - The ratio of the total num- 
ber of referrals to other physicians to 
the number of individual recipients 
(unduplicated count) served. 

02.19 RATIO OF HOSPITAL DISCHARGES TO RECIP- 
IENTS - The ratio of the total number 
of inpatient hospital discharges to the 
number of individual recipients (undu- 
plicated count) served. 

02.20 AVERAGE DAYS STAY PER HOSPITAL DISCHARGE 

- The ratio of the total days stay in 
inpatient hospitals to the total number 
of inpatient hospital discharges. 

02.21 PERCENT DISCHARGES TO LTCF - The per- 
centage of all inpatient hospital dis- 
charges which were to long term care 
facilities . 



-39- 



2.3.5.2 SUMMARY PROFILE REPORT: PHYSICIAN SERVICES 
REPORT CONTENT DEFINITION 
PROFILE REPORT ITEMS (Continued! 

Reference Number Report Item Title and Description 

02.22 PERCENT DISCHARGES TO HOME CARE - The 

percentage of all inpatient hospital 
discharges which were to home health 
care agencies. 

02.23 AVERAGE DAYS OF PREOPERATIVE STAY - The 

ratio of the total days stay in hospi- 
tals .prior to surgery to the number of 
inpatient hospital .discharges after 

surgery . 

02.24 RATIO OF LTCF PATIENTS TO RECIPIENTS - 

The ratio of the total number of 
patients residing in long term care 
facilities (unduplicated count) to the 
number of individual recipients (undu* 
plicated count) served. 

02.25 RATIO OF DRUG PRESCRIPTIONS TO VISITS - 

The ratio of the total number of drug 
prescriptions filled to the total num- 
ber of visits. 

02.26 RATIO OF DRUG PRESCRIPTIONS TO RECIP- 
IENTS - The ratio of the total number 
of drug prescriptions filled to the 
number of individual recipients (unduf 
plicatefd count) served. 

02.27 PERCENT COMPOUNDED DRUG PRESCRIPTIONS - 

The percentage of the total number of 
drug prescriptions which were classified 
as compounded. 



-4o- 



2.3.5.2 SUMMARY PROFILE REPORT: PHYSICIAN SERVICES 
REPORT CONTENT DEFINITION 
PROFILE REPORT ITEMS (Continued) 

Reference Number Report Item Title and Description 

02.28 PERCENT ADDICTIVE DRUG PRESCRIPTIONS - 

The percentage of the total number of 
drug prescriptions which were classified 
as addictive. 

02.29 PERCENT OVER-THE-COUNTER DRUG PRESCRIP- 
TIONS - The percentage of the total num- 
ber of drug prescriptions which were 
classified as over-the-counter. 

02.30 MAXIMUM INPATIENT HOSPITAL VISITS IN ONE 

DAY - A count of the maximum number of 
visits at inpatient hospitals in a 
single day. 

02.31 MAXIMUM LTCF VISITS IN ONE DAY - A count 

of the maximum number of visits at long 
term care facilities in a single day. 

02.32 MAXIMUM HOME VISITS IN ONE DAY - A count 

of the maximum number of visits at 
patients' homes in a single day. 



-4l- 



2.3.5.3 SUMMARY PROFILE REPORT: INPATIENT HOSPITAL SERVICES 

REPORT FORMAT EXAMPLE 
(On following page) 



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-43- 



3.5.3 SUMMARY PROFILE REPORT: INPATIENT HOSPITAL SERVICES 

REPORT CONTENT DEFINITION 
IDENTIFICATION REPORT ITEMS 



Reference Title 

NAME 
NUMBER 
LOCATION 
TYPE 

SPECIALTY 
SIZE 



Report Item Title 



PROVIDER NAME 

PROVIDER NUMBER 

PROVIDER COUNTY CODE 

PROVIDER TYPE CODE 

PROVIDER MEDICAL SPECIALTY CODE 

NUMBER OF BEDS IN HOSPITAL 



PROFILE REPORT ITEMS 



Reference Number 
01 

01.01 
01.02 



01.03 



01.04 



01,05 



Report Item Title and Descrip tion 
VOLUME SUMMARY SECTION 

TOTAL DOLLARS PAID - Total dollars paid 
by Title XIX. 

DOLLARS PAID - MEDICAID - Total dollars 
paid for services rendered under Title 
XIX. 

DOLLARS PAID - MEDICARE - Total dollars 
paid by Title XIX for services rendered 
with primary coverage under Title XVIII 
(coinsurance and deductible) . 

RECIPIENTS SERVED - TOTAL - An undupl i - 
cated count of all individual recipients 
served . 

RECIPIENTS SERVED - MEDICAID - An undu- 
plicated. count of individual recipients 
served with primary coverage under Title 
XIX. 



_44- 



2.3.5.3 SUMMARY PROFILE REPORT: INPATIENT HOSPITAL SERVICES 



REPORT CONTENT DEFINITION 
PROFILE REPORT ITEMS (Continued) 

Reference Number Report Item Title and Description 

01.06 RECIPIENTS SERVED - MEDICARE - An undu- 

plicated count of individual recipients 
served who were eligible under Title XIX 
but had primary coverage under Title 
XVIII. 

02 ESSENTIAL REPORT ITEM SECTION - All 

report items in this section refer to 
services rendered to recipients with 
primary coverage under Title XIX. 

02.01 AVERAGE STAY PER DISCHARGE - The ratio 

of the total days stay to the number of 
discharges . 

02.02 AVERAGE DAYS OF PREOPERATIVE STAY - The 

ratio of the total days stay prior to 
surgery to the number of surgical dis- 
charges . 

02.03 PERCENT DISCHARGES 1 DAY - The percent- 
age of the number of discharges after 
one day stay to the total number of dis- 
charges . 

02.04 PERCENT DISCHARGES 2 DAYS - The percent- 
age of the number of discharges after 
two days stay to the total number of dis 
charges . 

02.05 PERCENT DISCHARGES 3-7 DAYS - The per- 
centage of the number of discharges 
after 3 to 7 days stay to the total num- 
ber of discharges. 



2.3.5.3 SUMMARY PROFILE REPORT: INPATIENT HOSPITAL SERVICES 

REPORT CONTENT DEFINITION 
PROFILE REPORT ITEMS (Continued) 

Reference Number Report Item Title and Description 

02.06 PERCENTAGE DISCHARGES 8 DAYS UP - The 

percentage of the number of discharges 
after 8 or more days stay to the total 
number of discharges. 

02.07 PERCENTAGE DISCHARGES TO LTCF - The per- 
centage of the number of discharges to 
long term care facilities to the total 
number of discharges. 

02.06 PERCENTAGE DISCHARGES TO HOME CARE - 

The percentage of the number of dis- 
charges to home health care to the total 
number of discharges. 

02. 0$ PERCENT FRIDAY- SATURDAY ADMISSIONS - The 

percentage of the number of admissions 
on Friday and Saturday to total the num- 
ber of admissions. 

02.10 PERCENT SUNDAY-MONDAY DISCHARGES - The 

percentage of the number of discharges 
on Sunday and Monday to the total number 
of discharges. 

02.11 AVERAGE ANCILLARY PAYMENT PER DISCHARGE ■ 

The ratio of the total dollars paid for 
ancillary services to the total number 
of discharges. 

02.12 AVERAGE ANCILLARY PAYMENT PER SURGICAL 

DISCHARGE - The ratio of the total 
dollars paid for ancillary services for 
discharges after surgery to the total 
number of discharges after surgery, 



-46- 



2.3.5.3 SUMMARY PROFILE REPORT: INPATIENT HOSPITAL SERVICES 



REPORT CONTENT DEFINITION 
PROFILE REPORT ITEMS (Continued) 

Reference Number Report Item Title and Description 

0 2.13 AVERAGE ANCILLARY PAYMENT PER NON- 

SURGICAL DISCHARGE - The ratio of the 
total dollars paid for ancillary services 
after discharge with no surgery to the 
total number of discharges with no 
surgery. 

02.14 PERCENT PAYMENTS FOR ANCILLARY SERVICES - 

The percentage of the dollars paid for 
ancillary services to the total dollars 
paid . 

02.15 PERCENT PAYMENTS FOR ANCILLARIES - 

SURGICAL DISCHARGES - The percentage of 
the dollars paid for ancillary services 
for discharges after surgery to the 
total dollars paid for discharges after 
surgery. 

02.16 PERCENT PAYMENTS FOR ANCILLARIES - NON- 
SURGICAL DISCHARGES - The percentage of 
the dollars paid for ancillary services 
for discharges with no surgery to the 
total dollars paid for discharges with 
no surgery. 



-47- 



2.3.5.4 SUMMARY PROFILE REPORT: OUTPATIENT HOSPITAL SERVICES 



-48- 



3.5.4 SUMMARY PROFILE REPORT: OUTPATIENT HOSPITAL SERVICES 
REPORT CONTENT DEFINITION 
IDENTIFICATION REPORT ITEMS 



Reference Title 

NAME 
NUMBER 
LOCATION 
TYPE 

SPECIALTY 



Report Item Title 



PROVIDER NAME 

PROVIDER NUMBER 

PROVIDER COUNTY CODE 

PROVIDER TYPE CODE 

PROVIDER MEDICAL SPECIALTY CODE 



PROFILE REPORT ITEMS 



Reference Number 
01 

01.01 



01.02 



01. 03 



01.04 



01. 05 



Report Item Title and Description 

VOLUME SUMMARY SECTION 

TOTAL DOLLARS PAID - Total dollars paid 
by Title XIX. 

DOLLARS PAID - MEDICAID - Total dollars 
paid for services rendered under Title 
XIX. 

DOLLARS PAID - MEDICARE - Total dollars 
paid by Title XIX for services rendered 
with primary coverage under Title XVIII 
(coinsurance and deductible) . 

TOTAL RECIPIENTS SERVED - An undupli- 
cated count of all individual recipients 
served . 

RECIPIENTS SERVED - MEDICAID - An undu- 
plicated count of individual recipients 
served with primary coverage under Title 
XIX. 



-49- 



3.5.4 SUMMARY PROFILE REPORT : OUTPATIENT HOSPITAL SERVICES 
REPORT CONTENT DEFINITION 
PROFILE REPORT ITEMS (Continued) 

Reference Number Report Item Title and Description 

01.06 RECIPIENTS SERVED - MEDICARE - An undu- 

plicated count of individual recipients 
served who were eligible under Title XIX 
but had primary coverage under Title 
XVIII. 

02 ESSENTIAL REPORT ITEM SECTION - All 

report items in this section refer to 
services rendered to recipients with 
primary coverage under Title XIX. 

02.01 AVERAGE NUMBER OF VISITS PER RECIPIENT - 

The ratio of the total number of visits 
to the number of individual recipients 
(unduplicated count) served. 

02.02 RATIO OF INJECTIONS TO VISITS - The 

ratio of the total number of injections 
to the total number of visits. 

02.03 RATIO OF INJECTIONS TO RECIPIENTS - The 

ratio of the total number of injections 
to the number of individual recipients 
(unduplicated count) served. 

02.04 RATIO OF LABORATORY PROCEDURES TO 

RECIPIENTS - The ratio of the total num- 
ber of laboratory procedures to the num- 
ber of individual recipients (undupli- 
cated count) served. 

02.05 RATIO OF LABORATORY PROCEDURES TO 

VISITS - The ratio of the total number 
of laboratory procedures to the total 
number of visits. 



-50- 



3.5.4 S UMMARY PROFILE REPORT : OUTPATIENT HOSPITAL SERVICES 
REPORT CONTENT DEFINITION 
PROFILE REPORT ITEMS (Continued) 

Reference Number Report Item Title and Description 

02.06 RATIO OF DIAGNOSTIC RADIOLOGY PROCEDURES 

TO RECIPIENTS - The ratio of the total 
number of diagnostic radiology proce- 
dures to the number of individual recip- 
ients (unduplicated count) served. 

02.07 RATIO OF DIAGNOSTIC RADIOLOGY PROCEDURES 

TO VISITS - The ratio of the total num- 
ber of diagnostic radiology procedures 
to the total number of visits. 

02.08 RATIO OF OTHER DIAGNOSTIC PROCEDURES TO 

RECIPIENTS - The ratio of the total num- 
ber of other specific diagnostic proce- 
dures to the number of individual recip- 
ients (unduplicated count) served. 

02.09 RATIO OF OTHER DIAGNOSTIC PROCEDURES TO 

VISITS - The ratio of the total number 
of other specific diagnostic procedures 
to the total number of visits. 

02.10 RATIO OF SERVICES OF SPECIALISTS TO 

RECIPIENTS - The ratio of the total num- 
ber of services rendered by specialist 
physicians on referral to the number of 
individual recipients (unduplicated 
count) served. 

02.11 RATIO OF REFERRALS TO RECIPIENTS - The 

ratio of the total number of referrals 
to specialist physicians to the number 
of individual recipients (unduplicated 
count) served. 



-51- 



2.3.5.4 SUMMARY PROFILE REPORT: OUTPATIENT HOSPITAL SERVICES 

REPORT CONTENT DEFINITION 
PROFILE REPORT ITEMS (Continued) 

Reference Number Report Item Title and Description 

02.12 RATIO OF DRUG PRESCRIPTIONS TO VISITS - 

The ratio of the total number of drug 
prescriptions filled to the total number 
of visits. 

02.13 RATIO OF DRUG PRESCRIPTIONS TO RECIP- 
IENTS - The ratio of the total number of 
drug prescriptions filled to the number 
of individual recipients (unduplicated 
count) served. 

02.14 PERCENT COMPOUNDED DRUG PRESCRIPTIONS - 

The percentage of all drug prescriptions 
filled which were for compounded drugs. 

02.15 PERCENT ADDICTIVE DRUG PRESCRIPTIONS - 

The percentage of all drug prescriptions 
filled which were for addictive drugs. 

02.16 PERCENT OVER-THE-COUNTER DRUG PRESCRIP- 
TIONS - The percentage of all drug pre- 
scriptions filled which were for over- 
the-counter drugs. 



-52- 



2.3.5.5 SUMMARY PROFILE REPORT: LONG TERM CARE FACILITY SERVICES 



-53- 



2.3.5.5 SUMMARY PROFILE REPORT: LONG TERM CARE FACILITY SERVICES 

REPORT CONTENT DEFINITION 
IDENTIFICATION REPORT ITEMS 



Reference Title 

NAME 
NUMBER 
LOCATION 
TYPE 

SPECIALTY 
SIZE 



Report Item Title 



PROVIDER NAME 

PROVIDER NUMBER 

PROVIDER COUNTY CODE 

PROVIDER TYPE CODE 

PROVIDER MEDICAL SPECIALTY CODE 

NUMBER OF BEDS IN FACILITY 



PROFILE REPORT ITEMS 



Reference Number 
01 

01.01 



01.02 



01.03 



01.04 



01. 05 



Report Item Title and Description 
VOLUME SUMMARY SECTION 

TOTAL DOLLARS PAID - Total dollars paid 
by Title XIX. 

DOLLARS PAID - MEDICAID - Total dollars 
paid for services rendered under Title 
XIX. 

DOLLARS PAID - MEDICARE - Total dollars 
paid for services rendered with pi i T ary 
coverage under Title XVIII (coinsurance 
and deductible) . 

RECIPIENTS SERVED - TOTAL - An u dupli- 
cated count of all individual recipients 
served . 

RECIPIENTS SERVED - MEDICAID - An undu - 
plicated count of individual recipients 
served with primary coverage under Title 
XIX. 



-54- 



2.3.5.5 SUMMARY PROFILE REPORT: LONG TERM CARE FACILITY SERVICES 

REPORT CONTENT DEFINITION 
PROFILE REPORT ITEMS (Continued) 

Reference Number Report Item Title and Description 

01.06 RECIPIENTS SERVED - MEDICARE - An undu- 

plicated count of individual recipients 

served who were eligible under Title XIX 
but had primary coverage under Title 
XVIII. 

02 ESSENTIAL REPORT ITEM SECTION - All 

report items in this section refer to 
services rendered to recipients with 
primary coverage under Title XIX. 

02.01 AVERAGE DAYS STAY PER RESIDENT - The 

ratio of the total days stay of resident 
recipients to the number of individual 
resident recipients (unduplicated count) 

02.02 AVERAGE LEAVE DAYS PER RESIDENT - The 

ratio of the total number of leave days 
for other than outside medical care to 
the number of individual resident recip- 
ients (unduplicated count) . 

02.03 AVERAGE DAYS STAY PER DISCHARGE - The 

ratio of the total days stay prior to 
discharge to the total number of dis- 
charges . 

02.04 AVERAGE LEAVE DAYS PER DISCHARGE - The 

ratio of the total number of leave days 
prior to discharge for other than out- 
side medical care to the total number of 
discharges . 



-55- 



2.3.5.5 SUMMARY PROFILE REPORT: LONG TERM CARE FACILITY SERVICES 

REPORT CONTENT DEFINITION 
PROFILE REPORT ITEMS (Continued) 

Reference Number Report Item Title and Description 

02.05 PERCENT RESIDENTS WITH 1-30 DAYS STAY - 

The percentage of all resident recipients 
who were admitted from 1 to 30 days ago. 

02.06 PERCENT RESIDENTS WITH 31-60 DAYS STAY - 

The percentage of all resident recipients 
who were admitted from 31 to 60 days ago. 

02.07 PERCENT RESIDENTS WITH 61-90 DAYS STAY - 

The percentage of all resident recipients 
who were admitted from 61 to 90 days ago. 

02.08 PERCENT RESIDENTS WITH 91-120 DAYS STAY - 

The percentage of all resident recipients 
who were admitted from 91 to 120 days 
ago. 

02.09 PERCENT RESIDENTS WITH 121-150 DAYS 

STAY - The percentage of all resident 
recipients who were admitted from 121 to 
150 days ago. 

02.10 PERCENT RESIDENTS WITH OVER 150 DAYS 

STAY - The percentage of all resident 
recipients who were admitted more than 
150 days ago. 



-56- 



2.3.5,6 SUMMARY PROFILE REPORT: DENTAL SERVICES 



-57- 



2.3.5.6 SUMMARY PROFILE REPORT: DENTAL SERVICES 



REPORT CONTENT DEFINITION 
IDENTIFICATION REPORT ITEMS 



Reference Title 

NAME 
NUMBER 
LOCATION 
TYPE 

SPECIALTY 
SIZE 



Report Item Title 



PROVIDER NAME 

PROVIDER NUMBER 

PROVIDER COUNTY CODE 

PROVIDER TYPE CODE 

PROVIDER MEDICAL SPECIALTY CODE 

NUMBER OF DENTISTS IN GROUP 



PROFILE REPORT ITEMS 



Reference Number 
01 

01. 01 
01.02 



01.03 



01.04 



01.05 



Report Item Title and Description 
VOLUME SUMMARY SECTION 

TOTAL DOLLARS PAID - Total dollars paid 
by Title XIX. 

DOLLARS PAID - MEDICAID - Total dollars 
paid for services rendered under Title 

XIX. 

DOLLARS PAID - MEDICARE - Total dollars 
paid for services rendered with primary- 
coverage under Title XVIII (coinsurance 
and deductible) . 

RECIPIENTS SERVED - TOTAL - An undupli- 
cated count of all individual recipients 
served . 

RECIPIENTS SERVED - MEDICAID - An undu- 
plicated count of individual recipients 
served with primary coverage under Title 

XIX, 



2.3.5.6 SUMMARY PROFILE REPORT: DENTAL SERVICES 
REPORT CONTENT DEFINITION 
PROFILE REPORT ITEMS (Continued) 

Reference Number Report Item Title and Description 

01.06 RECIPIENTS SERVED - MEDICARE - An undup- 

licated count of individual recipients 
served who were eligible under Title XIX 
but had primary coverage under Title 
XVIII. 

02 ESSENTIAL REPORT ITEM SECTION - All 

report items in this section refer to 
services rendered to recipients with 
primary coverage under Title XIX. 

02.01 PERCENT PROCEDURES PRIOR AUTHORIZED - 

The percentage of all procedures which 
were performed with prior authorization. 

02.02 PERCENT RESTORATIVE PROCEDURES - The 

percentage of all procedures which were 
classified as restorative. 

02.03 PERCENT PREVENTIVE PROCEDURES - The 

percentage of all procedures which were 
classified as preventive. 

02.04 PERCENT PROSTHODONTIC PROCEDURES - The 

percentage of all procedures which were 
classified as prosthodontic . 

02.05 AVERAGE NUMBER OF PROSTHODONTIC PROCE- 
DURES PER RECIPIENT - The ratio of the 
total number of prosthodontic procedures 
to the number of individual recipients 
(unduplicated count) who received 
prosthodontic procedures. 



-59- 



2.3.5.6 SUMMARY PROFILE REPORT: DENTAL SERVICES 



REPORT CONTENT DEFINITION 
PROFILE REPORT ITEMS (Continued) 

Reference Number Report Item Title and Description 

02.06 AVERAGE NUMBER OF PROCEDURES PER RECIP- 

IENT - The ratio of the total number of 
procedures to the number of individual 
recipients (unduplicated count) served. 



-60- 



2.3,5.7 SUMMARY PROFILE REPORT: PRESCRIBED DRUGS 

REPORT FORMAT EXAMPLE 
(On following page) 



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-62- 



2.3.5.7 SUMMARY PROFILE REPORT: PRESCRIBED DRUGS 
REPORT CONTENT DEFINITION 
IDENTIFICATION REPORT ITEMS 



Reference Title 

NAME 
NUMBER 
LOCATION 
TYPE 



Report Item Title 



PROVIDER NAME 
PROVIDER NUMBER 
PROVIDER COUNTY CODE 
PROVIDER TYPE CODE 



PROFILE REPORT ITEMS 



Reference Number 
01 

01.01 
01.02 



02 

02.01 



02 . 02 



02 . 03 



Report Item Title and Description 
VOLUME SUMMARY SECTION 

TOTAL DOLLARS PAID - Total dollars paid 
by Title XIX. 

TOTAL RECIPIENTS SERVED - An undupli- 
cated count of all individual recipients 
served . 

ESSENTIAL REPORT ITEM SECTION 

NUMBER OF PRESCRIPTIONS FILLED - A count 
of individual prescriptions filled 
including refill prescriptions. 

AVERAGE NUMBER OF PRESCRIPTIONS PER 
RECIPIENT - The ratio of the total number 
of prescriptions filled to the number of 
individual recipients (undupl icated 
count) served. 

AVERAGE PAYMENT PER PRESCRIPTION - The 
ratio of total dollars paid to the total 
number of prescriptions. 



-63- 



2.3.5.7 SUMMARY PROFILE REPORT: PRESCRIBED DRUGS 
REPORT CONTENT DEFINITION 
PROFILE REPORT ITEMS (Continued) 

Reference Number Report Item Title and Description 

02.04 PERCENT REFILL PRESCRIPTIONS - The 

percentage of the number of refill pre- 
scriptions to the number of all pre- 
scriptions filled. 

02.05 PERCENT COMPOUNDED PRESCRIPTIONS - The 

percentage of the number of compounded 
prescriptions to the number of all pre- 
scriptions filled. 

02.06 PERCENT OVER-THE-COUNTER PRESCRIPTIONS - 

The percentage of the number of over- 
the-counter prescriptions to the number 
of all prescriptions filled. 

02.07 PERCENT PAYMENTS FOR PROFESSIONAL FEE - 

The percentage of total payments for 
professional fees to total payments. 

02.08 AVERAGE NUMBER OF PRESCRIPTIONS TO 

NURSING HOME RECIPIENTS - The ratio of 
the total number of prescriptions for 
nursing home recipients to the number of 
recipients residing in nursing hemes. 

02.09 AVERAGE PAYMENT PER PRESCRIPTION TO 

NURSING HOME RECIPIENTS - The ratio of 
total payments for prescriptions for 
nursing home recipients to the number of 
prescriptions for nursing home recip- 
ients . 



-64- 



2.3.5.7 SUMMARY PROFILE REPORT: PRESCRIBED DRUGS 



REPORT CONTENT DEFINITION 
PROFILE REPORT ITEMS (Continued) 

Reference Number Report Item Title and Description 

02.10 PERCENT RECIPIENTS WITH ADDICTIVE PRE- 
SCRIPTIONS - The percentage of recipients 
receiving addictive drug prescriptions to 
all recipients. 

02.11 AVERAGE NUMBER OF ADDICTIVE PRESCRIPTIONS 

PER RECIPIENT - The ratio of the number 
of addictive drug prescriptions to the 
number of recipients receiving addictive 
drug prescriptions. 



— "65 — 



2.3.5.8 SUMMARY PROFILE REPORT: OTHER PROVIDER SERVICES 



-66.- 



2.3.5.8 SUMMARY PROFILE REPORT: OTHER PROVIDER SERVICES 



REPORT CONTENT DEFINITION 
IDENTIFICATION REPORT ITEMS 



Reference Title 

NAME 
NUMBER 
LOCATION 
TYPE 

SPECIALTY 



Report Item Title 



PROVIDER NAME 

PROVIDER NUMBER 

PROVIDER COUNTY CODE 

PROVIDER TYPE CODE 

PROVIDER MEDICAL SPECIALTY CODE 



PROFILE REPORT ITEMS 



Reference Number Report Item Title and Description 

01 VOLUME SUMMARY SECTION 

01.01 TOTAL DOLLARS PAID - Total dollars paid 

by Title XIX. 

01.02 DOLLARS PAID - MEDICAID - Total dollars 

paid for services rendered under Title 
XIX. 

01.03 DOLLARS PAID - MEDICARE - Total dollars 

paid by Title XIX for services rendered 
with primary coverage under Title XVIII 
(coinsurance and deductible) . 

01.04 TOTAL RECIPIENTS SERVED - An undupli- 

cated count of all individual recipients 
served . 

01.05 RECIPIENTS SERVED - MEDICAID - An undu- 

plicated count of individual recipients 
served with primary coverage under Title 
XIX. 



-67- 



2.3.5.8 SUMMARY PROFILE REPORT: OTHER PROVIDER SERVICES 
REPORT CONTENT DEFINITION 
PROFILE REPORT ITEMS (Continued) 

Reference Number Report Item Title and Description 

01.06 RECIPIENTS SERVED - MEDICARE - An undu- 

plicated count of individual recipients 
served who were eligible under Title XIX 
but had primary coverage under Title 
XVIII. 

02 ESSENTIAL REPORT ITEM SECTION - All 

report items in this section refer to 
services rendered to recipients with 
primary coverage under Title XIX. 

02.01 NUMBER OF SERVICES PROVIDED - A count of 

all specific, individual services ren- 
dered . 

02.02 AVERAGE NUMBER OF SERVICES PER RECIP- 
IENT - The ratio of the total number of 
services rendered to the number of indi- 
vidual recipients (unduplicated count) 
served . 

02.03 AVERAGE PAYMENT PER SERVICE - The ratio 

of total dollars paid to the total num- 
ber of services rendered. 

02. 04 PERCENT OF SERVICES PRIOR AUTHORIZED - 

The percentage of the total number of 
services rendered which received prior 
authorization. 



-68- 



2.4 TREATMENT ANALYSIS REPORTS 



2.4.1 Intended Usage 

Treatment. Analysis Reports have been designed to 
facilitate a detailed analysis of diagnosis -treatment 
interrelationships exhibited in the care provided to 
Medicaid recipients by physicians and inpatient hos- 
pitals. These reports may be used as a screening mech- 
anism in a manner similar to that defined for Summary 
Profile Reports, and/or as a source of more detailed infor- 
mation to support investigation of exceptional utilization 
discovered through the use of Summary Profile Reports. 

2.4.2 Exception Processing Techniques 

The screening function of Treatment Analysis 
Reports is implemented through an automated exception 
processing technique. Conceptually, the exception 
processing technique requires six major steps on the 
part of the computer system. First, a statistical 
profile is developed from information contained in 
paid claims for each primary diagnosis code reported 
by each individual physician and inpatient hospital. 
If desired diagnosis code profiles may be further 
broken down by recipient age group. Each diagnosis 
code profile will consist of a number of statistical 
indicators relating to services rendered and pre- 
scribed in response to diagnosis. 

Second, the diagnosis code profiles of all physi- 
cians and inpatient hospitals are classified into groups 
of their peers. These groups are called Class Groups 
within the context of the S/UR Subsystem. There may be 
up to 50 Class Groups for each Category of Service. For 
any given run on the system, a provider may fall into 



-69- 



only one Class Group for each Category of Service which 
he is authorized to provide. 

Third, averages and standard deviations are com- 
puted by Class Group for each indicator contained within 
each diagnosis code profile. Only those indicators 
which are not zero, meaning that a provider was active 
in the area indicated, are taken into consideration for 
these computations. 

Fourth, the averages and standard deviations com- 
puted in step three are used to establish norms, or 
exception criteria by Class Group for each indicator in 
each diagnosis code profile. Exception criteria for 
any statistical indicator will consist of an upper and 
a lower limit. The upper limit will consist of the 
average plus a predetermined number of standard devia- 
tions. The lower limit may be set to either zero or to 
the average minus a predetermined number of standard 
deviations . 

Fifth, all diagnosis code profiles of all individ- 
ual providers within each Class Group are evaluated, 
indicator by indicator, against the matching exception 
criteria established for each Class Group. This eval- 
uation process consists of comparing each indicator of 
each diagnosis code profile against both the upper and 
lower limits of the matching exception criteria. If 
an indicator falls outside the established range of 
exception criteria values then an exception is noted. 
In order to limit the volume of this exception process- 
ing, a facility is provided to consider for exception 
only those providers who have surpassed a predetermined 
volume of activity for each diagnosis code reported. 

Sixth, all diagnosis code profiles for which at 

-TO- 



least one exception was noted during step five are 
printed out for manual review. The indicator or indi- 
cators which caused the exception are flagged on the 
printed report to facilitate the investigation process. 
At this point, the Medicaid activity of each individual 
provider has been evaluated against the mean activity 
of a group of his peers and is presented for further 
investigation only if an unusual deviation from that 
mean is noted. 

The validity of this technique of exception pro- 
cessing depends completely upon the validity of the 
statistical indicators chosen to serve as a basis for 
comparison, It is felt that . indicators which inter- 
relate various aspects of Medicaid activity will pro- 
duce much more meaningful results than will indicators 
which merely measure volume of activity. 

When Treatment Analysis Reports are used as a 
source of detailed information to support investiga- 
tion of misutilization, individual providers may be 
selected by number without regard to the exception pro- 
cessing procedures described above. When a provider is 
specifically selected, all of his diagnosis code pro- 
files are printed out for review. 

2.4.3 Organization and Format 

The major element of Treatment Analysis Report 
Organization is based on Category of Service. All physi 
cian diagnosis code profiles are printed in a group as 
are all inpatient hospital diagnosis code profiles. 
Within each Category of Service, the next level of organ 
ization is Class Group. Within each Class Group, diag- 
nosis code profiles are organized into sequence by provi 
der, and then into sequence by diagnosis code. 

-n- 



Each individual provider who is included in a 
Treatment Analysis Report is introduced with a series 
of identification and demographic data elements organ- 
ized into an Identification Section which is identical 
to that contained in equivalent Summary Profile Reports. 
Following the Identification Section will appear a 
series of diagnosis code profiles for that provider. 
Each diagnosis code profile consists of one printed 
line and will be followed by a detailed break out of 
services rendered for that diagnosis if requested by 
the user. For physicians this detailed break out con- 
sists of an itemization of procedure codes and of drug 
codes and therapeutic classes together with a count of 
the frequency of application of each such procedure or 
drug. For inpatient hospitals the detailed break out 
consists of an itemization of ancillary service codes 
together with a count of the frequency of application 
of each ancillary service. 

2.4.4 General Description of Content 

Each individual diagnosis code profile consists 
of a fixed set of statistical indicators or report items 
which are developed from paid claims with a date of 
service during the past twelve months. The detailed 
break out of services rendered also encompasses a twelve 
month time period on the basis of claim date of service. 
One fixed set of report items is developed for physician 
diagnosis code profiles, while a completely different 
fixed set is developed for inpatient hospital profiles. 
Data for physician diagnosis code profiles is drawn from 
physician claims, drug claims and inpatient hospital 
claims, whereas data for inpatient hospital profiles is 
drawn from inpatient hospital claims only. 



2.4.5 Individual Report Definitions 



The following pages contain a Report Format Example 
and a Report Content Definition for each of the two 
possible variations of Treatment Analysis Reports. Where 
Report Format Examples containing actual report item 
values have been included, an effort has been made to 
use realistic values, representative of a typical Medi- 
caid Program. However, the intent of these examples is 
only to illustrate what a Treatment Analysis Report might 
look like in actual production, and not to predict actual 
utilization patterns in a specific State Medicaid envi- 
ronment. All codes contained in these reports should be 
considered as being entirely fictitious since a specific 
code structure must be adopted to fit each State program. 

Report Content Definitions are keyed back to Report 
Format Examples by use of Reference Titles in the case of 
Identification Report Items, and Reference Number in the 
case of Profile Report Items. Detail Report Items con- 
sist only of multiple iterations of the same series of 
codes as described on the preceeding page under Organization 
and Format . These items must be defined by each user 
in terms of a specific coding structure for physician 
procedures, drugs, and hospital ancillary services. If 
a state should elect to have ancillary services reported 
on inpatient hospital claims as a gross charge or as 
charges by cost center rather than adopting a detailed 
coding structure for procedures, drugs and supplies, 
then Detail Report Items should be eliminated from the 
Treatment Analysis Report : Inpatient Hospital Services . 



-73- 



2.4.5.1 TREATMENT ANALYSIS REPORT: PHYSICIAN SERVICES 

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-75- 



2.4.5.1 TREATMENT ANALYSIS REPORT: PHYSICIAN SERVICES 



REPORT CONTENT DEFINITION 
IDENTIFICATION REPORT ITEMS 

Reference Title Report Item Title 

NAME PROVIDER NAME 

NUMBER PROVIDER NUMBER 

LOCATION PROVIDER COUNTY CODE 

TYPE PROVIDER TYPE CODE 

SPECIALTY PROVIDER MEDICAL SPECIALTY CODE 

SIZE NUMBER OF PHYSICIANS IN GROUP 



PROFILE REPORT ITEMS 



One line of Profile Report Items is produced for each age group 
within each diagnosis code. The actual information associated with 
each Profile Report Item is derived from Medicaid claims (excluding 
crossover claims for Medicare coinsurance and deductible) for ser- 
vices rendered during the most current twelve month time period. 
Each profile line applies only to the diagnosis code and age group 
indicated above it. In the following definition of Profile Report 
Items, reference numbers correspond to the numbers above each field 
on the report format example. 



Reference Number Report Item Title and Description 

1 NUMBER OF RECIPIENTS SERVED - An undu- 

plicated count of all individual 
recipients served. 

2 TOTAL NUMBER OF PHYSICIAN PROCEDURES • 

A count of the total number of proce- 
dures rendered. 



2.4.5.1 TREATMENT ANALYSIS REPORT: PHYSICIAN SERVICES 
REPORT CONTENT DEFINITION 
PROFILE REPORT ITEMS (Continued) 

R eference Number Report Item Title and Description 

3 AVERAGE NUMBER OF PHYSICIAN PROCEDURES 

FOR RECIPIENT - The ratio of the total 
number of physician procedures to the 
number of recipients served. 

4 NUMBER OF DIFFERENT PHYSICIAN PROCEDURES 

An unduplicated count of different 
physician procedures rendered. 

5 TOTAL NUMBER OF DRUG PRESCRIPTIONS - 

A count of the total number of filled 
drug prescriptions by this physician. 

6 AVERAGE NUMBER OF DRUG PRESCRIPTIONS 

PER RECIPIENT - The ratio of the total 
number of drug prescriptions to the 
number of recipients served. 

7 NUMBER OF DIFFERENT DRUGS - An un- 
duplicated count of different drugs 
prescribed by this physician and pro- 
vided to his recipients. 

8 TOTAL NUMBER OF HOSPITAL DISCHARGES - 

A count of the total number of hospital 
discharges after hospital stays attended 
by this physician. 

9 AVERAGE NUMBER OF HOSPITAL DISCHARGES 

PER RECIPIENT - The ratio of the total 
number of hospital discharges to the 
number of recipients served. 



-77- 



2.4.5.1 TREATMENT ANALYSIS REPORT: PHYSICIAN SERVICES 



REPORT CONTENT DEFINITION 
PROFILE REPORT ITEMS (Continued) 

Reference Number Report Item Title and Description 

10 TOTAL NUMBER OF DAYS OF HOSPITAL STAY - 

A count of the total number of days of 
hospital stay attended by this physi- 
cian . 

11 AVERAGE NUMBER OF DAYS OF HOSPITAL STAY 

PER DISCHARGE - The ratio of the total 
number of days of hospital stay to the 
total number of hospital discharges. 



-78 



2.4.5.2 TREATMENT ANALYSIS REPORT: INPATIENT HOSPITAL SERVICES 

REPORT FORMAT EXAMPLE 
(On following page) 



-79- 



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2.4.5.2 TREATMENT ANALYSIS REPORT: INPATIENT HOSPITAL SERVICES 



REPORT CONTENT DEFINITION 
IDENTIFICATION REPORT ITEMS 

Reference Title Report Item Title 

NAME PROVIDER NAME 

NUMBER PROVIDER NUMBER 

LOCATION PROVIDER COUNTY CODE 

TYPE PROVIDER TYPE CODE 

SPECIALTY PROVIDER MEDICAL SPECIALTY CODE 

SIZE NUMBER OF BEDS IN HOSPITAL 



PROFILE REPORT ITEMS 



One line of Profile Report Items is produced for each age group 
within each diagnosis code. The actual information associated with 
each Profile Report Item is derived from Medicaid Claims (excluding 
crossover claims for Medicare coinsurance and deductible) for ser- 
vices rendered during the most current twelve month time period. 
Each profile line applies only to the diagnosis code and age group 
indicated above it. In the following definition of Profile Report 
Items, reference numbers correspond to the numbers above each field 
on the report format example. 



Reference Number Report Item Title and Description 

1 NUMBER OF NON- SURGICAL DISCHARGES - A 

count of the total number of discharges 
after hospital stays including no sur- 
gery. 

2 TOTAL NUMBER OF DAYS STAY FOR NON- 
SURGICAL DISCHARGES - A count of the 
total number of days of hospital stay 
including no surgery which have been 
completed by discharge. 



-81- 



2.4.5.2 TREATMENT ANALYSIS REPORT: INPATIENT HOSPITAL SERVICES 



REPORT CONTENT DEFINITION 
PROFILE REPORT ITEMS (Continued) 

Reference Number Report Item Title and Description 

3 AVERAGE NUMBER OF DAYS STAY PER NON- 
SURGICAL DISCHARGE - The ratio of the 
total number of days stay for non- 
surgical discharges to the total num- 
ber of non-surgical discharges. 

4 TOTAL CHARGES FOR NON- SURGICAL DIS- . 

CHARGES - An accumulation of the total 
dollars charged for discharges after 
hospital stays involving no surgery. 

5 ANCILLARY SERVICE CHARGES FOR NON- 
SURGICAL DISCHARGES - An accumulation 
of the total dollars charged for 
ancillary services associated with 
non-surgical discharges. 

6 PERCENT OF NON-SURGICAL DISCHARGE 

CHARGES FOR ANCILLARY SERVICES - The 
percentage of ancillary service 
charges for non-surgical discharges to 
total charges for non-surgical dis- 
charges . 

7 NUMBER OF SURGICAL DISCHARGES - A 

count of the total number of discharges 
after hospital stays including surgery. 

8 TOTAL NUMBER OF DAYS STAY FOR SURGICAL 

DISCHARGES - A count of the total num- 
ber of days of hospital stay including 
surgery which have been completed by 
discharge . 

-82- 



2.4.5.2 TREATMENT ANALYSIS REPORT: INPATIENT HOSPITAL SERVICES 



REPORT CONTENT DEFINITION 
PROFILE REPORT ITEMS (Continued) 



Reference Number Report Item Title and Description 

9 AVERAGE NUMBER OF DAYS STAY PER SUR- 

GICAL DISCHARGE - The ratio of the 
total number of days stay for surgical 
discharges to the total number of sur- 
gical discharges. 

10 TOTAL CHARGES FOR SURGICAL DISCHARGES - 

An accumulation of the total dollars 
charged for discharges after hospital 
stays including surgery. 

11 ANCILLARY SERVICE CHARGES FOR SURGICAL 

DISCHARGES - An accumulation of the 
total dollars charged for ancillary 
services associated with surgical 
discharges . 

12 PERCENT OF SURGICAL DISCHARGE CHARGES 

FOR ANCILLARY SERVICES - The percentage 
of ancillary service charges for sur- 
gical discharges to total charges for 
surgical discharges. 



2.5 MANAGEMENT SUMMARY REPORTS 



2.5.1 Intended Usage 

Management Summary Reports correspond on a one 
for one basis to Summary Profile Reports and Treatment 
Analysis Reports. Whereas Summary Profile Reports and 
Treatment Analysis Reports present information for 
individual Medicaid participants, Management Summary 
Reports present equivalent information for participant 
Class Groups and for provider Categories of Service. 
These reports are primarily intended to support the 
exception processing techniques employed in the pro- 
duction of their corresponding Summary Profile and 
Treatment Analysis Reports. To this end Management 
Summary Reports provide a means by which the statistical 
validity of each user defined Class Group may be veri- 
fied; and by which realistic exception criteria may be 
established where system generated criteria are not 
acceptable. Management Summary Reports are secondarily 
intended to provide management and administrative per- 
sonnel with a detailed presentation of the overall 
utilization patterns of the various Medicaid services. 

2.5.2 Organization and Format 

Management Summary Reports corresponding to Summary 
Profile Reports are organized into two major groupings: 
one for provider class profiles and one for recipient 
class profiles. Provider class profiles are organized 
into sequence by Class Group Within Category of Service. 
Recipient class profiles are organized into sequence by 
Class Group. 

Management Summary Reports corresponding to Treat- 
ment Analysis Reports are also organized into two major 



-84- 



groupings: one for physician services and one for 
inpatient hospitals. Within each of these groupings, 
treatment analysis class profiles are organized into 
sequence by Class Group. Within each Class Group, 
treatment analysis class profiles are organized by age 
group within diagnosis code. 

Each provider and recipient class profile consists 
of three sections: one showing Class Group totals, one 
showing Class Group averages and standard deviations, 
and one showing Class Group frequency distributions 
when requested. The totals section of a class profile 
consists of a series of summary data items organized 
into a matrix format. Each summary data item occupies 
one line or row of the matrix. Each such row consists 
of an index number and an abbreviated title for its 
summary data item followed by a series of numerical 
values which have been summarized from data contained 
in paid claims. Each of these values represents activ- 
ity in the category indicated by the summary data item 
title for one specific time period. For providers, six 
time periods are represented on the report. The first 
time period covers data from claims paid in the current 
month regardless of date of service. The second through 
the sixth time periods cover data from paid claims with 
a date of service during the current quarter of the cur- 
rent year, the comparable current quarter from the last 
year, one quarter ago, two quarters ago, and three quar- 
ters ago respectively. For recipients, the current month 
time period is omitted from the matrix described above, 
thus showing the five quarterly time periods only. 

The averages and standard deviations section of a 
class profile consists of a series of statistical indi- 
cators organized into a matrix format which is identical 
to that described for corresponding Summary Profile 



Reports. Whereas a row on a Summary Profile Report 
matrix consists of only one line of numerical values 
pertaining to an individual provider or recipient, a 
row in a corresponding class profile matrix consists 
of two lines of numerical values pertaining to a Class 
Group. The first of these lines contains Class Group 
averages and the second of these lines contains Class 
Group standard deviations, both by time periods indi- 
cated for Summary Profile Reports. 

The frequency distributions section of a class 
profile is produced only when specifically requested 
by the user. Each frequency distribution printed will 
correspond to one time period of one statistical indi- 
cator contained in the averages and standard deviations 
section. The number, title, and time period covered is 
displayed at the top of each frequency distribution. 
Beneath this identification data are printed three 
columns of numbers. The first such column contains a 
sequential class number always starting with "1" and 
going no higher than n 50". The second column contains 
a series of continuous value ranges each of which, 
except for the first and last, have the same class 
interval. The first value range is zero or less and 
the last value range starts after its immediate prede- 
cessor and runs to the highest value actually encoun- 
tered in the distribution. The third column contairs a 
series of counts indicating the number of providers or 
recipients whose value for the statistical indicator 
under consideration fell into each range. Up to three 
frequency distributions for a class profile may be 
printed on each page. 

Each treatment analysis class profile is printed 
in the same basic format as that described for its 
corresponding Treatment Analysis Report. Instead of 

-86- 



the one line diagnosis profile for an individual pro- 
vider contained in Treatment Analysis Reports, treat- 
ment analysis class profiles consist of three lines. 
The first of these lines contains Class Group totals, 
the second contains Class Group averages, and the third 
contains Class Group standard deviations. The format 
of treatment analysis class profile detailed informa- 
tion is identical to that defined for corresponding 
Treatment Analysis Reports. 

2.5.3 General Description of Content 

In general, the content of Management Summary 
Reports represents an accumulation of the content of 
corresponding Summary Profile Reports. Whereas a Sum- 
mary Profile Report presents data for an individual 
provider or recipient, a Management Summary Report 
presents data for a Class Group of providers or recip- 
ients . 

Each Management Summary Report contains total, 
average and standard deviation information. Total infor- 
mation is an accumulation of the basic data used to pro- 
duce Summary Profile or Treatment Analysis Reports. 
Average and standard deviation information presents a 
profile representing an average provider or recipient in 
a Class Group. 

2.5.4 Individual Report Definitions 

The following pages contain a Report Format Example 
and a Report Content Definition for each of the major 
variations of Management Summary Reports. Where Report 
Format Examples containing actual report item values 
have been included, an effort has been made to use real- 
istic values, representative of a typical Medicaid 



-87- 



Program. However, the intent of these examples is only 
to illustrate what Management Summary Reports might 
look like in actual production, and not to predict 
actual utilization patterns in a specific State Medi- 
caid Environment. All codes contained in these report 
examples should be considered as being entirely ficti- 
tious since a specific code structure must be adopted 
to fit each State Program. 

Report Content Definitions are keyed back to Report 
Format Examples by use of reference numbers. In order 
to demonstrate the correlation of Management Summary 
Reports to Summary Profile Reports and Treatment Analysi 
Reports and to eliminate redundant detailed definitions, 
Report Content Definitions of Management Summary Reports 
refer back to matching Summary Profile and Treatment 
Analysis Reports where ever appropriate . 



-88- 



2.5.4.1 MANAGEMENT SUMMARY REPORT: RECIPIENT CLASS PROFILES 

REPORT FORMAT EXAMPLE 
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-92- 



5.4.1 MANAGEMENT SUMMARY REPORT: RECIPIENT CLASS PROFILES 



REPORT CONTENT DEFINITION 
TOTALS SECTION 

The Totals Section contains summary data items described 
below. Each summary data item represents an accumulation of 
equivalent, individual data items for all recipients in the 
Class Group reported. The set of individual data items for a 
given recipient contains basic data necessary to compute all 
profile report items for that recipient as defined for the 
Summary Profile Report: Recipient . 

SUMMARY DATA ITEMS 

Reference Number Reference Title and Description 

001 DOLLARS PAID-MEDICAID - Total dollars 

paid for services rendered under Title 
XIX. 

002 DOLLARS PAID-MEDICARE - Total dollars 

paid by Title XIX for services rendered 
with primary coverage under Title XVIII 
(coinsurance and deductible) . 

003 DOLLARS PAID TOTAL - Total dollars paid 

by Title XIX. 

0 04 NUMBER OF DIFFERENT PRIMARY DIAGNOSES 

005 NUMBER OF DIFFERENT PHYSICIANS - An 

unduplicated count of individual physi- 
cians, physician groups, or physician 
clinics seen. 

NUMBER OF MEDICAL VISITS 

NUMBER OF INITIAL MEDICAL VISITS 

NUMBER OF DRUG PRESCRIPTIONS 

NUMBER OF REFILL DRUG PRESCRIPTIONS 



006 
007 
008 
009 



-93- 



/ 



2.5.4.1 MANAGEMENT SUMMARY REPORT: RECIPIENT CLASS PROFILES 



REPORT CONTENT DEFINITION 
SUMMARY DATA ITEMS (Continued) 
Reference Number Reference Title and Description 



010 


NUMBER 


OF 


ADDICTIVE DRUG PRESCRIPTIONS 


Oil 


NUMBER 


OF 


DIFFERENT DRUGS 


012 


NUMBER 


OF 


PROSTHETICS AND EYEGLASSES 


013 


NUMBER 


OF 


DENTAL SERVICES 


014 


NUMBER 


OF 


DENTAL EMERGENCIES 


015 


NUMBER 


OF 


TRANSPORTATION SERVICES 


016 


NUMBER 


OF 


OPTOMETRIC SERVICES 


017 


NUMBER 


OF 


PODIATRIC SERVICES 


018 


NUMBER 


OF 


DAYS IN HOSPITALS 


019 


NUMBER 


OF 


DAYS IN LONG TERM CARE FACILITIES 



AVERAGES AND STANDARD DEVIATIONS SECTION 

This section contains averages and standard deviations for each 
profile report item of all recipients in the Class Group being re- 
ported. An average for each profile report item is computed by 
taking the sum of that item for all recipients in the Class Group 
and then dividing that sum by the number of recipients in the 
Class Group who had a non-zero value for that item. A non-zero 
value for a profile report item of an individual recipient means 
that recipient was active in the area indicated by the item, A 
standard deviation for each profile report item is computed bv 
taking the sum of the squares of the differences between th^ aver- 
age of that item and the individual values of that item for all recip- 
ients in the Class Group active for that item, dividing that sum by 
the number of active recipients for that item, and taking the square 
root of the dividend. The standard deviation from the average of a 
profile report item provides a consistent measure of the dispersion 
of individual recipient item values about the average. A small 
standard deviation indicates that individual item values are closely 

-9h- 



.5.4.1 M ANAGEMENT SUMMARY REPORT: RECIPIENT CLASS PROFILES 

REPORT CONTENT DEFINITION 
AVERAGES AND STANDARD DEVIATIONS (Continued) 



grouped about the average, while a large standard deviation 
indicates that individual item values are widely scattered 
about the average. 

The detailed report content definition of profile report 
items for the Summary Profile Report: Recipient is equally 
applicable to the Management Summary Report : Recipient Class 
Profiles and, therefore, is not repeated here. 



FREQUENCY DISTRIBUTIONS SECTION 

This section is optional and will only be produced at the 
specific request of the user. .When produced it will contain 
frequency distributions for individual time periods of profile 
report items. Each frequency distribution contains a series 
of continuous value ranges together with a count of the number 
of recipients who had profile report item values falling into 
each range. It is possible to produce frequency distributions 
for all time periods of all profile report items defined for 
the Summary Profile Report: Recipient. 



-95- 



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-100- 



2.5.4.2 MANAGEMENT SUMMARY REPORT: PHYSICIAN SERVICES CLASS PROFILES 



REPORT CONTENT DEFINITION 
TOTALS SECTION 

The Totals Section contains summary data items described 
below. Each summary data item represents an accumulation of 
equivalent, individual data items for all providers in the Class 
Group or Category of Service reported. The set of individual 
data items for a given provider contains basic data necessary to 
compute all profile report items for that provider as defined 
for the Summary Profile Report: Physician Services. 



SUMMARY DATA ITEMS 



Reference Number Data Item Title and Description 

001 DOLLARS PAID-TOTAL - Total dollars paid 

by Title XIX. 

002 DOLLARS PAID-MEDICAID - Total dollars 

paid for services rendered under Title 
XIX. 

003 DOLLARS PAID-MEDICARE - Total dollars 

paid by Title XIX for services rendered 
with primary coverage under Title XVIII 
(coinsurance and deductible) . 

004 RECIPIENTS SERVED-TOTAL - An undupli- 

cated count of all individual recipients 
served. 

005 RECIPIENTS SERVED -MEDICAID - An undu- 

plicated count of individual recipients 
served with primary coverage under Title 
XIX. 



-101- 



2 MANAGEMENT SUMMARY REPORT: PHYSICIAN SERVICES CLASS PROFILES 
REPORT CONTENT DEFINITION 
SUMMARY DATA ITEMS (Continued) 

Reference Number Data Item Title and Description 

006 RECIPIENTS SERVED -MED I CARE - A count of 

individual recipients served, who were 
eligible under Title XIX but had primary- 
coverage under Title XVIII. 

007 RECIPIENTS SERVED-OFFICE - An undupli- 

cated count of all individual recipients 
served in office. 

008 RECIPIENTS SERVED-HOME - An unduplicated 

count of all individual recipients 
served at home. 

009 RECIPIENTS SERVED- INPATIENT HOSPITALS - 

An unduplicated count of all individual 
recipients served at inpatient hospitals. 

010 RECIPIENTS SERVED- LTCF - An unduplicated 

count of all individual recipients 
served who reside in long term care 
facilities . 

011 RECIPIENTS SERVED -OUTPATIENT HOSI ITALS - 

An unduplicated count of all individual 
recipients served at outpatient hospitals 

012 NUMBER OF VISITS-OFFICE - Total lumber 

of visits in office. 

013 NUMBER OF VISITS-HOME - Total number of 

visits at patients' homes. 

014 NUMBER OF VISITS- INPATIENT HOSPITAL - 

Total number of visits at inpatient 
hospitals . 



-102- 



2.5.4.2 M ANAGEMENT SUMMARY REPORT: PHYSICIAN SERVICES CLASS PROFILES 

REPORT CONTENT DEFINITION 
SUMMARY DATA ITEMS (Continued) 

Reference Number Data Item Title and Description 

015 NUMBER OF VISITS-LTCF - Total number of 

visits at long term care facilities. 

016 NUMBER OF VISITS-OUTPATIENT HOSPITALS - 

Total number of visits at outpatient 
hospitals . 

017 NUMBER OF VISITS-TOTAL - Total number of 

visits at all locations. 

018 NUMBER OF INJECTIONS-TOTAL - Total num- 
ber of injections given at all locations. 

019 NUMBER OF INJECTIONS-OFFICE - Total 

number of injections given in office. 

020 TOTAL DAYS STAY- INPATIENT HOSPITAL 

021 TOTAL DAYS STAY-LTCF 

022 NUMBER OF SURGICAL PROCEDURES 

023 NUMBER OF DIAGNOSTIC RADIOLOGY PROCEDURES 
0 24 NUMBER OF LABORATORY PROCEDURES 

025 NUMBER OF OTHER DIAGNOSTIC PROCEDURES - 

Total number of other specific diag- 
nostic procedures. 

026 NUMBER OF OTHER PHYSICIAN SERVICES - 

Total number of services rendered by- 
other physicians on referral. 

027 NUMBER OF OTHER PHYSICIAN REFERRALS - 

Total number of referrals to other 
physicians . 



-103- 



2.5.4.2 MANAGEMENT SUMMARY KL.. ■ ! PHYSICIAN SERVICES CLASS PROFILES 



REPORT CONTENT DEFINITION 
SUMMARY DATA ITEMS (Continued) 

Reference Number Data Item Title and Description 

02 8 NUMBER OF HOSPITAL DISCHARGES 

029 NUMBER OF HOSPITAL DISCHARGES- SURGICAL 

Total number of hospital discharges 
after surgery. 

030 NUMBER OF DISCHARGES TO LTCF - Total 

number of hospital discharges to long 
term care facilities. 

Oil NUMBER OF DISCHARGES TO HOME CARE - 

Total number of hospital discharges to 
home health care. 

032 NUMBER OF DAYS OF PREOPERATIVE STAY - 

Total number of days of inpatient 
hospital stay prior to surgery. 

033 NUMBER OF DRUG PRESCRIPTIONS -TOTAL 

034 NUMBER OF COMPOUNDED DRUG PRESCRIPTIONS 

035 NUMBER OF ADDICTIVE DRUG PRESCRIPTIONS 

0 36 NUMBER OF OVER-THE-COUNTER DRUG PRE- 

SCRIPTIONS 



AVERAGES AND STANDARD DEVIATIONS SECTION 

This section contains averages and standard deviations for 
each profile report item of all providers in the Class Group or 
Category of Service being reported. An average for each profile 
report item is computed by taking the sum of that item for all 
providers in the Class Group and then dividing that sum by the 
number of providers in the Class Group who had a non-zero value 
for that item. A non-zero value for a profile report item of an 

-104- 



2.5.4.2 MANAGEMENT SUMMARY REPORT: PHYSICIAN SERVICES CLASS PROFILES 



REPORT CONTENT DEFINITION 
AVERAGES AND STANDARD DEVIATIONS SECTION (Continued) 

individual provider means that provider was active in the area 
indicated by the item. A standard deviation for each profile 
report item is computed by taking the sum of the squares of the 
differences between the average of that item and the individual 
values of that item for all providers in the Class Group active 
for that item, dividing that sum by the number of active provi- 
ders for that item, and taking the square root of the dividend. 
The standard deviation from the average of a profile report item 
provides a consistent measure of the dispersion of individual 
provider item values about the average. A small standard devia- 
tion indicates that individual item values are closely grouped 
about the average, while a large standard deviation indicates 
that individual item values are widely scattered about the 
average . 

The detailed report content definition of profile report 
items for the Summary Profile Report: Physicians Services is 
equally applicable to the Management Summary Report : Physician 
Services Class Profiles and, therefore, is not repeated here. 



FREQUENCY DISTRIBUTIONS SECTION 

This section is optional and will only be produced at the 
specific request of the user. When produced it will contain 
frequency distributions for individual time periods of profile 
report items. Each frequency distribution contains a series of 
continuous value ranges together with a count of the number of 
providers who had profile report item values falling into each 
range. It is possible to produce frequency distributions for 
all time periods of all profile report items defined for the 
Summary Profile Report : Physician Services . 



-105- 



2.5.4.3 MANAGEMENT SUMMARY REPORT: INPATIENT HOSPITAL 

SERVICES CLASS PROFILES 

REPORT FORMAT EXAMPLE 
(On following page) 



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-108- 



2.5.4.3 MANAGE M ENT SUMMARY REPORT: INPATIENT HOSPITAL 

SERVICES CLASS PROFILES 

REPORT CONTENT DEFINITION 
TOTALS SECTION 

The Totals Section contains summary data items described 
below. Each summary data item represents an accumulation of 
equivalent, individual data items for all providers in the Class 
Group or Category of Service reported. The set of individual 
data items for a given provider contains basic data necessary to 
compute all profile report items for that provider as defined 
for the Summary Profile Report: Inpatient Hospital Services. 

SUMMARY DATA ITEMS 

Reference Number Reference Title and Description 

001 DOLLARS PAID TOTAL - Total dollars paid 

by Title XIX. 

002 DOLLARS PAID MEDICAID - Total dollars 

paid for services rendered under Title 
XIX. 

003 DOLLARS PAID MEDICARE - Total dollars 

paid by Title XIX for services rendered 
with primary coverage under Title XVIII 
(coinsurance and deductible). 

004 DOLLARS PAID- SURGICAL DISCHARGE - Total 

dollars paid for discharges after sur- 
gery. 

005 DOLLARS PAID-NON- SURGICAL DISCHARGE - 

Total dollars paid for discharges with 
no surgery. 

006 ANCILLARY PAYMENTS -TOTAL - Total dollars 

paid for ancillary services. 



-109- 



2.5.4.3 MANAGEMENT SUMMARY REPORT: INPATIENT HOSPITAL 

SERVICES GLASS PROFILES 

RE PORT . CONTENT DEFINITION 

SUMMARY DATA ITEMS (Continued) 

Reference Number Reference Title and Description 

007 ANCILLARY PAYMENTS- SURGICAL DISCHARGE - 

Total dollars paid for ancillary ser- 
vices for discharges after surgery. 

008 ANCILLARY PAYMENTS -NON -SURGICAL DIS- 
CHARGE - Total dollars paid for ancillary 
services for discharges with no surgery. 

009 RECIPIENTS SERVED-TOTAL - An undupli- 

cated count of all recipients served. 

010 RECIPIENTS SERVED -MEDICAID - An undupli- 

cated count of all recipients served 
with primary coverage under Title XIX. 

011 RECIPIENTS SERVED -MEDICARE - An undupli- 

cated count of all recipients served who 
were eligible under Title XIX but had 
primary coverage under Title XVIII. 

012 NUMBER OF HOSPITAL DISCHARGES -TOTAL 

013 NUMBER OF HOSPITAL DISCHARGES -SURGICAL - 

Total number of hospital discharges 
after surgery. 

014 NUMBER OF HOSPITAL DISCHARGES -NON- 
SURGICAL - Total number of hospital dis- 
charges with no surgery. 

015 NUMBER OF DISCHARGES TO LTCF - Total 

number of hospital discharges to long 
term care facilities. 



-110- 



2.5.4.3 MA NAGEMENT SUMMARY REPORT: INPATIENT HOSPITAL 

SERVICES CLASS PROFILES 

REPORT CONTENT DEFINITION 

SUMMARY DATA ITEMS (Continued) 

Reference Number Reference Title and Description 

016 NUMBER OF DISCHARGES TO HOME CARE - 

Total number of hospital discharges to 
home health care. 

017 NUMBER OF DISCHARGES- SUNDAY-MONDAY - 

Total number of hospital discharges on 
Sunday or Monday. 

018 NUMBER OF DISCHARGES- 1 DAY - Total number 

of discharges after 1 day of stay. 

019 NUMBER OF DISCHARGES- 2 DAYS - Total num- 
ber of discharges after 2 days of stay. 

020 NUMBER OF DISCHARGES- 3 - 7 DAYS -Total 

number of discharges after 3 to 7 days 
of stay. 

021 NUMBER OF DISCHARGES-8 DAYS UP - Total 

number of discharges after 8 or more 
days of stay. 

022 TOTAL DAYS STAY - Total days of hospital 

stay. 

023 TOTAL DAYS PREOPERATIVE STAY - Total 

days of stay prior to surgery. 

024 NUMBER OF ADMISSIONS-TOTAL 

025 NUMBER OF ADMISSIONS-FRIDAY-SATURDAY - 

Total number of hospital admissions on 
Friday or Saturday. 



-Ill- 



2.5.4.3 MANAGEMENT SUMMARY REPORT: INPATIENT HOSPITAL 



SERVICES CLASS PROFILES 
REPORT CONTENT DEFINITION 
AVERAGES AND STANDARD DEVIATIONS SECTION 

This section contains averages and standard deviations for 
each profile report item of all providers in the Class Group or 
Category of Service being reported. An average for each profile 
report item is computed by taking the sum of that item for all 
providers in the Class Group and then dividing that sum by the 
number of providers in the Class Group who had a non-zero value 
for that item. A non-zero value for a profile report item of an 
individual provider means that provider was active in the area 
indicated by the item. A standard deviation for each profile 
report item is computed by taking the sum of the squares of the 
differences between the average of that item and the individual 
values of that item for all providers in the Class Group active 
for that item, dividing that sum by the number of active provi- 
ders for that item, and taking the square root of the dividend. 
The standard deviation from the average of a profile report 
item provides a consistent measure of the dispersion of individ- 
ual provider item values about the average. A small standard 
deviation indicates that individual item values are closely 
grouped about the average, while a large standard deviation indi- 
cates that individual item values are widely scattered about the 
average . 

The detailed report content definition of profile report 
items for the Summary Profile Report: In patient Hospital Ser - 
vices is equally applicable to the Management Su mmary Report : 
Inpatient Hospital Services Class Profiles and, therefore, is 
not repeated here. 



-112- 



2.5.4.3 MANAGEMENT SUMMARY REPORT: INPATIENT HOSPITAL 

SERVICES CLASS PROFILES 

REPORT CONTENT DEFINITION 

FREQUENCY DISTRIBUTIONS SECTION 

This section is optional and will only be produced at the 
specific request of the user. When produced it will contain 
frequency distributions for individual time periods of profile 
report items. Each frequency distribution contains a series 
of continuous value ranges together with a count of the number 
of providers who had profile report item values falling into 
each range. It is possible to produce frequency distributions 
for all time periods of all profile report items defined for 
the Summary Profile Report: Inpatient Hospital Services. 



-113- 



2.5.4.4 MANAGEMENT SUMMARY REPORT: OUTPATIENT HOSPITAL 

SERVICES CLASS PROFILES 

REPORT FORMAT EXAMPLE 
(On following page) 



-114- 



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-115- 



2.5.4.4 MANAGEMENT SUMMARY REPORT: OUTPATIENT HOSPITAL 

SERVICES CLASS PROFILES 

REPORT CONTENT DEFINITION 

TOTALS SECTION 

The Totals Section contains summary data items described 
below. Each summary data item represents an accumulation of 
equivalent, individual data items for all providers in the 
Class Group or Category of Service reported. The set of indi- 
vidual data items for a given provider contains basic data 
necessary to compute all profile report items for that provider 
as defined for the Summary Profile Report: Outpatient Hospital 
Services . 



SUMMARY DATA ITEMS 



Reference Number 



Data Item Title and Description 



002 



001 



DOLLARS PAID-TOTAL - Total dollars paid 
by Title XIX. 

DOLLARS PAID-MEDICAID - Total dollars 



paid for services rendered under Title 



XIX. 



003 



DOLLARS PAID-MEDICARE - Total dollars 



paid by Title XIX for services :endered 
with primary coverage under Title XVIII 
(coinsurance and deductible) . 



004 



RECIPIENTS SERVED-TOTAL - An ^dupli- 



cated count of all individual recipients 
served . 



005 



RECIPIENTS SERVED -MEDICAID - An undupli- 
cated count of individual recipients 
served with primary coverage under Title 



XIX. 



-116- 



2.5.4.4 MANAGEMENT SUMMARY REPORT: OUTPATIENT HOSPITAL 

SERVICES CLASS PROFILES 

REPORT CONTENT DEFINITION 

SUMMARY DATA ITEMS (Continued) 

Reference Number Data Item Title and Description 

006 RECIPIENTS SERVED -MED I CARE - A count of 

individual recipients served, who were 
eligible under Title XIX but had primary- 
coverage under Title XVIII. 

007 NUMBER OF VISITS - Total number of 

visits. 

008 NUMBER OF INJECTIONS - Total number of 

injections given. 

009 NUMBER OF LABORATORY PROCEDURES 

010 NUMBER OF DIAGNOSTIC RADIOLOGY PROCEDURES 

011 NUMBER OF OTHER DIAGNOSTIC PROCEDURES - 

Total number of other specific diagnostic 
procedures . 

012 NUMBER OF OTHER PHYSICIAN SERVICES - 

Total number of services rendered by- 
other physicians on referral. 

013 NUMBER OF OTHER PHYSICIAN REFERRALS - 

Total number of referrals to other physi- 
cians . 

014 TOTAL NUMBER OF DRUG PRESCRIPTIONS 

015 NUMBER OF PRESCRIPTIONS FOR COMPOUNDED 

DRUGS 

016 NUMBER OF PRESCRIPTIONS FOR ADDICTIVE 

DRUGS 

017 NUMBER OF PRESCRIPTIONS FOR OVER-THE- 
COUNTER DRUGS 

-117- 



2.5.4.4 MANAGEMENT SUMMARY REPORT: OUTPATIENT HOSPITAL 



SERVICES CLASS PROFILES 
REPORT CONTENT DEFINITION 
AVERAGES AND STANDARD DEVIATIONS SECTION 

This section contains averages and standard deviations for 
each profile report item of all providers in the Class Group or 
Category of Service being reported. An average for each profile 
report item is computed by taking the sum of that item for all 
providers in the Class Group and then dividing that sum by the 
number of providers in the Class Group who had a non-zero value 
for that item. A non-zero value for a profile report item of 
an individual provider means that provider was active in the 
area indicated by the item. A standard deviation for each pro- 
file report item is computed by taking the sum of the squares of 
the differences between the average of that item and the individ- 
ual values of that item for all providers in the Class Group 
active for that item, dividing that sum by the number of active 
providers for that item, and taking the square root of the divi- 
dend. The standard deviation from the average of a profile 
report item provides a consistent measure of the dispersion of 
individual provider item values about the average. A small 
standard deviation indicates that individual item values are 
closely grouped about the average, while a large standard devia- 
tion indicates that individual item values are widely scattered 
about the average. 

The detailed report content definition of profile report 
items for the Summary Profile Report : Outpatient H ospital Ser- 
vices is equally applicable to the Management Summ ary Report: 
Outpatient Hospital Services Class Profiles and, therefore, is 
not repeated here. 



-118- 



2.5.4.4 MANAGEMENT SUMMARY REPORT: OUTPATIENT HOSPITAL 



SERVICES CLASS PROFILES 
REPORT CONTENT DEFINITION 
FREQUENCY DISTRIBUTIONS SECTION 

This section is optional and will only be produced at the 
specific request of the user. When produced it will contain 
frequency distributions for individual time periods of profile 
report items. Each frequency distribution contains a series 
of continuous value ranges together with a count of the number 
of providers who had profile report item values falling into 
each range. It is possible to produce frequency distributions 
for all time periods of all profile report items defined for 
the Summary Profile Report: Outpatient Hospital Services. 



-119- 



2.5.4.5 MANAGEMENT SUMMARY REPORT: LONG TERM CARE FACILITY 

SERVICES CLASS PROFILES 

REPORT FORMAT EXAMPLE 
tun tollowmg page J 



-120- 



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-121- 



2.5.4.5 MANAGEMENT SUMMARY REPORT: LONG TERM CARE FACILITY 

SERVICES CLASS PROFILES 

REPORT CONTENT DEFINITION 

TOTALS SECTION 

The Totals Section contains summary data items described 
below. Each summary data item represents an accumulation of 
equivalent, individual data items for all providers in the Class 
Group or Category of Service reported. The set of individual 
data items for a given provider contains basic data necessary to 
compute all profile report items for that provider as defined 
for the Summary Profile Report: Long Term Care Facility Services. 



SUMMARY DATA ITEMS 



Reference Number 



Data Item Title and Description 



001 



DOLLARS PAID-TOTAL - Total dollars paid 
by Title XIX. 



002 



DOLLARS PAID-MEDICAID - Total dollars 



paid for services rendered under Title 



XIX. 



003 



DOLLARS PAID-MEDICARE - Total dollars 



paid by Title XIX for services rendered 
with primary coverage under Title XVIII 
(coinsurance and deductible) . 



004 



RECIPIENTS SERVED-TOTAL - An uncupli- 
cated count of all individual recipients 
served . 



005 



RECIPIENTS SERVED -MEDICAID - An undupli- 
cated count of individual recipients 
served with primary coverage under Title 



XIX. 



-122- 



2.5.4.5 MANAGEMENT SUMMARY REPORT: LONG TERM CARE FACILITY 

SERVICES CLASS PROFILES 

REPORT CONTENT DEFINITION 

SUMMARY DATA ITEMS (Continued) 

Reference Number Data Item Title and Description 

006 RECIPIENTS SERVED -MED I CARE - A count of 

individual recipients served, who were 
eligible under Title XIX but had primary 
coverage under Title XVIII. 

007 TOTAL NUMBER OF RESIDENT RECIPIENTS - 

An unduplicated count of all individual 
recipients resident at the end of the 
period . 

008 NUMBER OF RESIDENT RECIPIENTS WITH 1-30 

DAYS STAY - An unduplicated count of all 
resident recipients who were admitted 
from 1 to 30 days ago. 

009 NUMBER OF RESIDENT RECIPIENTS WITH 31-60 

DAYS STAY - An unduplicated count of all 
resident recipients who were admitted 
from 31 to 60 days ago. 

010 NUMBER OF RESIDENT RECIPIENTS WITH 61-90 

DAYS STAY - An unduplicated count of all 
resident recipients served who were 
admitted from 61 to 90 days ago. 

011 NUMBER OF RESIDENT RECIPIENTS WITH 91- 

12 0 DAYS STAY - An unduplicated count of 
all resident recipients who were 
admitted from 91 to 120 days ago. 



-123- 



\ 



2.5.4.5 MANAGEMENT SUMMARY REPORT: LONG TERM CARE FACILITY 



SERVICES CLASS PROFILES 
— 



REPORT CONTENT DEFINITION 
SUMMARY DATA ITEMS (Continued) 

Reference Number Data Item Title and Description 

012 NUMBER OF RESIDENT RECIPIENTS WITH 121- 

150 DAYS STAY - An unduplicated count of 
all resident recipients who were 
admitted from 121 to 150 days ago. 

013 NUMBER OF RESIDENT RECIPIENTS WITH OVER 

150 DAYS STAY - An unduplicated count of 
all resident recipients who were 
admitted more than 150 days ago. 

014 TOTAL DAYS STAY- RESIDENT RECIPIENTS - 

Total days stay during the period for 
recipients resident at the end of the 
period . 

015 TOTAL DAYS STAY PRIOR TO DISCHARGE 

016 TOTAL LEAVE DAYS-RESIDENT RECIPIENTS 

017 TOTAL LEAVE DAYS PRIOR TO DISCHARGE 

018 NUMBER OF DISCHARGES 



AVERAGES AND STANDARD DEVIATIONS SECTION 
———————— 

This section contains averages and standard deviations for 
each profile report item of all providers in the Class Group or 
Category of Service being reported. An average for each profile 
report item is computed by taking the sum of that item for all 
providers in the Class Group and then dividing that sum by the 
number of providers in the Class Group who had a non-zero value 
for that item. A non-zero value for a profile report item of 
an individual provider means that provider was active in the 
area indicated by the item. A standard deviation for each 

-124- 



.5.4.5 MANAGEMENT SUMMARY REFORT: LONG TERM CARE FACILITY 



SERVICES CLASS PROFILES 
REPORT CONTENT DEFINITION 
AVERAGES AND STANDARD DEVIATIONS SECTION (Continued) 

profile report item is computed by taking the sum of the squares 
of the differences between the average of that item and the 
individual values of that item for all providers in the Class 
Group active for that item, dividing that sum by the number of 
active providers for that item, and taking the square root of 
the dividend. The standard deviation from the average of a pro- 
file report item provides a consistent measure of the dispersion 
of individual provider item values about the average. A small 
standard deviation indicates that individual item values are 
closely grouped about the average, while a large standard devia- 
tion indicates that individual item values are widely scattered 
about the average. 

The detailed report content definition of profile report 
items for the Summary Profile Report: Long Term Care Facility 
Services is equally applicable to the Management Summary Report: 
Long Term Care Facility Services Class Profiles and, therefore, 
is not repeated here. 

FREQUENCY DISTRIBUTIONS SECTION 

This section is optional and will only be produced at the 
specific request of the user. When produced it will contain 
frequency distributions for individual time periods of profile 
report items. Each frequency distribution contains a series of 
continuous value ranges together with a count of the number of 
providers who had profile report item values falling into each 
range. It is possible to produce frequency distributions for 
all time periods of all profile report items defined for the 
Summary Profile Report: Long Term Care Facility Services. 



-125- 



2.5.4.6 MANAGEMENT SUMMARY REPORT: DENTAL SERVICES CLASS PROFILES 

REPORT FORMAT EXAMPLE 
(On following page) 



-126- 



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-127- 



2.5.4.6 MANAGEMENT SUMMARY REPORT: DENTAL SERVICES CLASS PROFILES 



REPORT CONTENT DEFINITION 
TOTALS SECTION 

The Totals Section contains summary data items described 
below. Each summary data item represents an accumulation of 
equivalent, individual data items for all providers in the Class 
Group or Category of Service reported. The set of individual 
data items for a given provider contains basic data necessary to 
compute all profile report items for that provider as defined 
for the Summary Profile Report: Dental Services. 



SUMMARY DATA ITEMS 



Reference Number Data Item Title and Description 

001 DOLLARS PAID-TOTAL - Total dollars paid 

by Title XIX. 

002 DOLLARS PAID-MEDICAID - Total dollars 

paid for services rendered under Title 

XIX. 

003 DOLLARS PAID-MEDICARE - Total dollars 

paid by Title XIX for services rendered 
with primary coverage under Title XVIII 
(coinsurance and deductible) . 

004 RECIPIENTS SERVED- TOTAL - An undupli- 

cated count of all individual rec ; r)ients 
served . 

005 RECIPIENTS SERVED -MEDICAID - An undu- 

plicated count of individual recipients 
served with primary coverage under Title 
XIX. 



-128- 



2.5.4.6 MANAGEMENT SUMMARY REPORT: DENTAL SERVICES CLASS PROFILES 



REPORT CONTENT DEFINITION 
SUMMARY DATA ITEMS (Continued) 

Reference Number Data Item Title and Description 

006 RECIPIENTS SERVED -MEDICARE - A count of 

individual recipients served, who were 
eligible under Title XIX but had primary- 
coverage under Title XVIII. 

007 RECIPIENTS SERVED -PROSTHODONTIC PROCE- 
DURES - An unduplicated count of all 
individual recipients who received 
prosthodontic procedures. 

008 TOTAL NUMBER OF PROCEDURES 

009 NUMBER OF PROCEDURES PRIOR AUTHORIZED 

010 NUMBER OF RESTORATIVE PROCEDURES 

011 NUMBER OF PREVENTIVE PROCEDURES 

012 NUMBER OF PROSTHODONTIC PROCEDURES 

AVERAGES AND STANDARD DEVIATIONS SECTION 



This section contains averages and standard deviations for 
each profile report item of all providers in the Class Group or 
Category of Service being reported. An average for each profile 
report item is computed by taking the sum of that item for all 
providers in the Class Group and then dividing that sum by the 
number of providers in the Class Group who had a non-zero value 
for that item. A non-zero value for a profile report item of 
an individual provider means that provider was active in the 
area indicated by the item. A standard deviation for each pro- 
file report item is computed by taking the sum of the squares 
of the differences between the average of that item and the 
individual values of that item for all providers in the Class 



-129- 



.6 MANAGEMENT SUMMARY REPORT: DENTAL SERVICES CLASS PROFILES 
REPORT CONTENT DEFINITION 
AVERAGES AND STANDARD DEVIATIONS SECTION (Continued) 

Group active for that item, dividing that sum by the number of 
active providers for that item, and taking the square root of 
the dividend. The standard deviation from die average of a 
profile report item provides a consistent measure of the dis- 
persion of individual provider item values about the average. 
A small standard deviation indicates that individual item values 
are closely grouped about the average, while a large standard 
deviation indicates that individual item values are widely 
scattered about the average. 

The detailed report content definition of profile report 
items for the Summary Profile Report : Dental Services is equally 
applicable to the Management Summary Report : Dental Services 
Class Profiles and, therefore, is not repeated here. 

FREQUENCY DISTRIBUTIONS SECTION 

This section is optional and will only be produced at the 
specific request of the user. When produced it will contain 
frequency distributions for individual time periods of profile 
report items. Each frequency distribution contains a series of 
continuous value ranges together with a count of the number of 
providers who had profile report item values falling into each 
range. It is possible to produce frequency distributions for 
all time periods of all profile report items defined for the 
Summary Profile Report: Dental Services. 



-130- 



2.5.4.7 MANAGEMENT SUMMARY REPORT: PRESCRIBED DRUGS CLASS PROFILES 

REPORT FORMAT EXAMPLE 
(On following page) 



-131- 



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-133- 



2.5.4.7 MANAGEMENT SUMMARY REPORT: PRESCRIBED DRUGS CLASS PROFILES 



REPORT CONTENT DEFINITION 
TOTALS SECTION 

The totals Section contains summary data items described 
below. Each summary data item represents an accumulation of 
equivalent, individual data items for all providers in the 
Class Group or Category of Service reported. The set of indi- 
vidual data items for a given provider contains basic data 
necessary to compute all profile report items for that provider 
as defined for the Summary Profile Report: Prescribed Drugs. 



SUMMARY DATA ITEMS 



Reference Number Reference Title and Description 

001 DOLLARS PAID-TOTAL - Total dollars paid 

by Title XIX. 

002 DOLLARS PAID FOR PROFESSIONAL FEE 

003 DOLLARS PAID-NURSING HOME RECIPIENTS - 

Total dollars paid for prescriptions to 
recipients in nursing homes. 

004 RECIPIENTS SERVED -TOTAL - An undupli- 

cated count of all individual recipients 
served . 

005 RECIPIENTS SERVED- NURSING HOME -'An 

unduplicated count of recipients served 
who are residing in nursing homes. 

006 RECIPIENTS SERVED -ADDICTIVE PRESCRIP- 
TIONS - An unduplicated count of recip- 
ients served receiving one or more 
addictive drug prescriptions. 

007 NUMBER OF PRESCRIPTIONS FILLED 

008 NUMBER OF REFILL PRESCRIPTIONS 



-13^- 



2.5.4.7 MANAGEMENT SUMMARY REPORT: PRESCRIBED DRUGS CLASS PROFILES 



REPORT CONTENT DEFINITION 



SUMMARY DATA ITEMS (Continued) 



Reference Number 



Reference Title and Description 



009 



NUMBER OF COMPOUNDED PRESCRIPTIONS 



010 



NUMBER OF OVER-THE-COUNTER SUPPLIES 



Oil 



NUMBER OF PRESCRIPTIONS-NURSING HOME - 



Total number of prescriptions to recip- 
ients residing in nursing homes. 



012 



NUMBER OF ADDICTIVE PRESCRIPTIONS 



AVERA GES AND STANDARD DEVIATIONS SECTION 

This section contains averages and standard deviations for 
each profile report item of all providers in the Class Group or 
Category of Service being reported. An average for each profile 
report item is computed by taking the sum of that item for all 
providers in the Class Group and then dividing that sum by the 
number of providers in the Class Group who had a non-zero value 
for that item. A non-zero value for a profile report item of 
an individual provider means that provider was active in the 
area indicated by the item. A standard deviation for each pro- 
file report item is computed by taking the sum of the squares of 
the differences between the average of that item and the individ- 
ual values of that item for all providers in the Class Group 
active for that item, dividing that sum by the number of active 
providers for that item, and taking the square root of the divi- 
dend. The standard deviation from the average of a profile 
report item provides a consistent measure of the dispersion of 
individual provider item values about the average. A small 
standard deviation indicates that individual item values are 
closely grouped about the average, while a large standard devia- 
tion indicates that individual item values are widely scattered 
about the average. 



-135- 



2.5.4.7 MANAGEMENT SUMMARY REPORT: PRESCRIBED DRUGS CLASS PROFILES 

REPORT CONTENT DEFINITION 
AVERAGES AND STANDARD DEVIATIONS SECTION (Continued) 

The detailed report content definition of profile report 
items for the Summary Profile Report: Prescribed Drugs is 
equally applicable to the Management Summary Report: Prescribed 
Drugs Class Profiles and, therefore, is not repeated here. 

FREQUENCY DISTRIBUTIONS SECTION 

This section is optional and will only be produced at the 
specific request of the user. When produced it will contain 
frequency distributions for individual time periods of profile 
report items. Each frequency distribution contains a series of 
continuous value ranges together with a count of the number of 
providers who had profile report item values falling into each 
range. It is possible to produce frequency distributions for 
all time periods of all profile report items defined for the 
Summary Profile Report: Prescribed Drugs . 



-136- 



2.5.4.8 MANAGEMENT SUMMARY REPORT: OTHER PROVIDER SERVICES 

CLASS PROFILES 



-137- 



5.4.8 MANAGEMENT SUMMARY REPORT: OTHER PROVIDER SERVICES 

CLASS PROFILES 

REPORT CONTENT DEFINITION 

TOTALS SECTION 

The Totals Section contains summary data items described 
below. Each summary data item represents an accumulation of 
equivalent, individual data items for all providers in the 
Class Group or Category of Service reported. The set of indi- 
vidual data items for a given provider contains basic data 
necessary to compute all profile report items for that provider 
as defined for the Summary Profile Report: Other Provider 
Services . 



SUMMARY DATA ITEMS 



Reference Number 



Data Item Title and Description 



001 



DOLLARS PAID-TOTAL - Total dollars paid 
by Title XIX. 



002 



DOLLARS PAID-MEDICAID - Total dollars 



paid for services rendered under Title 



XIX. 



003 



DOLLARS PAID-MEDICARE - Total dollars 
paid by Title XIX for services rendered 
with primary coverage under Title XVIII 
(coinsurance and deductible) . 



004 



RECIPIENTS SERVED- TOTAL - An undupli- 
cated count of all individual recipients 
served . 



005 



RECIPIENTS SERVED -MEDICAID - An undupli- 
cated count of individual recipients 
served with primary coverage under Title 



XIX. 



-138- 



.5.4.8 MANAGEMENT SUMMARY REPORT: OTHER PROVIDER SERVICES 



CLASS PROFILES 
REPORT CONTENT DEFINITION 
SUMMARY DATA ITEMS (Continued) 

Reference Number Data Item Title and Description 

006 RECIPIENTS SERVED -MEDICARE - A count of 

individual recipients served, who were 
eligible under Title XIX but had primary- 
coverage under Title XVIII. • 

007 NUMBER OF SERVICES PROVIDED - A count 

of all specific individual services 
rendered . 

008 NUMBER OF SERVICES PRIOR AUTHORIZED - A 

count of all services which received 
prior authorization. 



AVERAGES AND STANDARD DEVIATIONS SECTION 



This section contains averages and standard deviations for 
each profile report item of all providers in the Class Group or 
Category of Service being reported. An average for each profile 
report item is computed by taking the sum of that item for all 
providers in the Class Group and then dividing that sum by the 
number of providers in the Class Group who had a non-zero value 
for that item. A non-zero value for a profile report item of 
an individual provider means that provider was active in the 
area indicated by the item. A standard deviation for each pro- 
file report item is computed by taking the sum of the squares of 
the differences between the average of that item and the individ- 
ual values of that item for all providers in the Class Group 
active for that item, dividing that sum by the number of active 
providers for that item, and taking the square root of the divi- 
dend. The standard deviation from the average of a profile 



-139- 



5.4.8 MANAGEMENT SUMMARY REPORT: OTHER PROVIDER SERVICES 



CLASS PROFILES 
REPORT CONTENT DEFINITION 
AVERAGES AND STANDARD DEVIATIONS SECTION (Continued) 

report item provides a consistent measure of the dispersion of 
individual provider item values about the average. A small 
standard deviation indicates that individual item values are 
closely grouped about the average, while a large standard devia- 
tion indicates that individual item values are widely scattered 
about the average. 

The detailed report content definition of profile report 
items for the Summary Profile Report: Other Provider Services 
is equally applicable to the Management Summary Report : Other 
Provider Services Class Profiles and, therefore, is not repeated 
here . 

FREQUENCY DISTRIBUTIONS SECTION 

This section is optional and will only be produced at the 
specific request of the user. When produced it will contain 
frequency distributions for individual time periods of profile 
report items. Each frequency distribution contains a series of 
continuous value ranges together with a count of the number of 
providers who had profile report item values falling into each 
range. It is possible to produce frequency distributions for 
all time periods of all profile report items defined for the 
Summary Profile Report: Other Provider Services . 



-l4o- 



2.5,4.9 MANAGEMENT SUMMARY REPORT: PHYSICIAN TREATMENT 

ANALYSIS CLASS PROFILES 

REPORT FORMAT EXAMPLE 
(On following page) 



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-142- 



2.5.4.9 MANAGEMENT SUMMARY REPORT: PHYSICIAN TREATMENT 

ANALYSIS CLASS PROFILES 

REPORT CONTENT DEFINITION 

Profile report items contained in the Management Summary- 
Report: Physician Treatment Analysis Class Profiles are shown 
as three lines of report item values containing Class Group or 
Category of Service totals, averages, and standard deviations 
respectively. Total lines represent an accumulation of equiv- 
alent, individual report items for all providers in the Class 
Group or Category of Service reported. All averages shown on 
the total line are computed from other total figures shown on 
the total line in the same manner as defined for the Treatment 
Analysis Report: Physician Services . The detailed report con- 
tent definition of profile report items for the treatment anal- 
ysis report is equally applicable to the management summary 
report except that a count of active providers in the Class 
Group is added to the total line. 

Average lines are computed by taking the sum of all profile 
report items for all providers in the Class Group, including 
average report items, and dividing each sum by the number of 
active providers shown on the total line. Standard deviation 
lines are computed by taking the sum of the squares of the dif- 
ferences between the average of each profile report item and the 
individual values of each item for all active providers in the 
Class Group, dividing each sum by the number of active providers 
shown on the total line, and taking the square root of each 
dividend. The standard deviation from the average of a profile 
repoit item provides a consistent measure of the dispersion of 
individual provider item values about the average. 



-143- 



2.5.4.10 MANAGEMENT SUMMARY REPORT: INPATIENT HOSPITAL 
TREATMENT ANALYSIS CLASS PROFILES 

REPORT FORMAT EXAMPLE 
(On following page) 



-144- 







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-145- 



2.5.4.10 MANAGEMENT SUMMARY REPORT: INPATIFNT HOSPITAL 
TREATMENT ANALYSIS CLASS PROFILES 

REPORT CONTENT DEFINITION 

Profile report items contained in the Management Summary 
Report: Inpatient Hospital Treatment Analysis Class Profiles 
are shown as three lines of report item values containing Class 
Group or Category of Service totals, averages, and standard 
deviations respectively. Total lines represent an accumulation 
of equivalent, individual report items for all providers in the 
Class Group or Category of Service reported. All averages shown 
on the total line are computed from other total figures shown on 
the total line in the same manner as defined for the Treatment 
Analysis Report: Inpatient Hospital Services. The detailed 
report content definition of profile report items for the treat- 
ment analysis report is equally applicable to the management 
summary report except that a count of active providers in the 
Class Group is added to the total line. 

Average lines are computed by taking the sum of all profile 
report items for all providers in the Class Group, including 
average report items, and dividing each sum by the number of 
active providers shown on the total line. Standard deviation 
lines are computed by taking the sum of the squares of the dif- 
ference between the average of each profile report item and the 
individual values of each item for all active providers in the 
Class Group, dividing each sum by the number of active providers 
shown on the total line, and taking the square root of each 
dividend . 



-146- 



2.6 CLAIM DETAIL REPORTS 



2.6.1 Intended Usage 

Claim Detail Reports are available to the user to 
provide access to information from selected paid claims 
for selected providers and recipients. The primary 
intended usage of these reports is to support analysis 
of exceptional utilization of the Medicaid Program 
identified by Summary Profile Reports and/or Treatment 
Analysis Reports. 

2.6.2 Selection Capabilities 

Claim Detail Reports are produced only when speci- 
fically requested by the user. All paid claims or file 
for one or more specific providers and/or recipients may 
be selected for printing on the report at any given time. 
For any given provider or recipient additional selectiv- 
ity may be applied to control the claims of that provi- 
der or recipient which are to be included in the report. 
This selectivity may be applied against any one or all 
of the following data elements: Category of Service, 
Date(s) of Service, Diagnosis Code, and Procedure Code. 
Selection parameters entered by the user would provide 
for a range of values for each of the above indicated 
data elements. Any claim having values falling within 
all of the ranges specified for the indicated data 
elements would be selected for printing on the report. 

2.6.3 Organization and Format 

Claim Detail Reports are organized into two major 
groupings: one for providers and one for recipients. 
Within the provider grouping, reports are organized into 
ascending sequence by Provider Number, Category of 



-147- 



Service, Recipient ID Number, and Beginning Date of 
Service. Within the recipient grouping, the report is 
in ascending sequence by Recipient ID Number, Category 
of Service, Beginning Date of Service, and Provider 
Number. 

For each claim selected, one or more lines of data 
elements are printed on the report. In the case of 
institutional and supplier claims only one line of data 
elements is printed per claim. In the case of practi- 
tioner claims, one line is printed for each line item 
included in the claim record. A line item in a practi- 
tioner claim represents one individual service rendered 
and, typically, a number of such services for a single 
recipient may be included in one claim document. 

2.6.4 General Description of Content 

The content of each line on a Claim Detail Report 
consists of basic data elements selected from the claim 
document. The set of basic data elements displayed on 
each line varies according to the Category of Service of 
the claim selected. In general, data elements are selec 
ted for display according to their value in describing 
the service or services rendered, the timing of such ser 
vices and their cost to the Medicaid program. 

2.6.5 Individual Report Definitions 

The following pages contain a Report Format Example 
and a Report Content Definition for each of the possible 
variations of Claim Detail Reports. Where Report Format 
Examples containing actual report item values have been 
included, an effort has been made to use realistic 
values, representative of a typical Medicaid program. 
However, the intent of these examples is only to 



-148- 



illustrate what a Claim Detail Report might look like 
in actual production, and not to predict actual utili- 
zation patterns in a specific State Medicaid environ- 
ment. All codes contained in these report examples 
should be considered as being entirely fictitious since 
a specific code structure must be adopted to fit each 
State program. 

Report Content Definitions are keyed back to 
Report Format Examples by use of Reference Titles in 
the case of Identification Report Items, and Reference 
Numbers in the case of Detail Data Elements. 



-149- 



2.6.5.1 CLAIM DETAIL REPORT: RECIPIENT 

REPORT FORMAT EXAMPLE 
(On following page) 



-150- 











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-I5I- 



2.6.5.1 CLAIM DETAIL REPORT: RECIPIENT 
REPORT CONTENT DEFINITION 
IDENTIFICATION REPORT ITEMS 



Reference Title 

NAME 

NUMBER 

LOCATION 

BIRTHDATE 

RACE 

SEX 

AID CATEGORY 

MONEY PAYMENT 

THIRD PARTY LIABILITY 



Report Item Title 



RECIPIENT NAME 

RECIPIENT IDENTIFICATION NUMBER 

RECIPIENT COUNTY CODE 

RECIPIENT DATE OF BIRTH 

RECIPIENT RACE CODE 

RECIPIENT SEX CODE 

RECIPIENT AID CATEGORY 

MONEY PAYMENT CODE 

THIRD PARTY LIABILITY CODE 



DETAIL DATA ELEMENTS 
PHYSICIAN SERVICES 



Reference Number 



Data Element Title and Description 

PROVIDER NUMBER - A unique number 
assigned by the State to each provider 
of services in the Medicaid program. 

TRANSACTION CONTROL NUMBER - A uni.que 
number serving to identify each claim 
transaction received. 

TRANSACTION CODE - A code which indi- 
cates the type of claim transaction and 
the processing to be done. 

REFERRING PHYSICIAN NUMBER - The provi- 
der number of the physician, if any, who 
referred the recipient to the physician 
filing a claim. 



-152- 



2.6.5.1 CLAIM DETAIL REPORT: RECIPIENT 



REPORT CONTENT DEFINITION 
DETAIL DATA ELEMENTS (Continued) 

Reference Number Data Element Title and Description 

5 PRIMARY DIAGNOSIS CODE - A code identi- 
fying the principal condition requiring 
medical attention. 

6 BEGINNING DATE OF SERVICE - The data 

upon which the first service covered by 
the claim was rendered. 

7 ENDING DATE OF SERVICE - The date upon 

which the last service covered by the 
claim was rendered. 

8 PLACE OF SERVICE - An abbreviated indi- 
cation of the physical location at which 
service was rendered by the physician 
(e.g., OFF = Physician's Office, IP = 
Inpatient Hospital, etc.) 

9 PROCEDURE CODE - A code identifying the 

medical service rendered. 

10 UNITS OF SERVICE - A count of the number 

of times the medical service indicated 
by the procedure code was rendered. 

11 PROCEDURE CHARGE - The dollar amount 

charged by the physician for services 
rendered . 

12 PAYMENT AMOUNT - The approved amount 

paid to the physician for services 
rendered . 

13 PAYMENT DATE - The date on which a pay- 
ment instrument was produced for the 
claim. 

-153- 



2.6.5.1 CLAIM DETAIL REPORT: RECIPIENT 
REPORT CONTENT DEFINITION 
DETAIL DATA ELEMENTS (Continued") 
INPATIENT HOSPITAL SERVICES 

Reference Number Data Element Title and Description 

1 PROVIDER NUMBER 

2 TRANSACTION CONTROL NUMBER 

3 TRANSACTION CODE 

4 ATTENDING PHYSICIAN NUMBER - The provi- 
der number of the physician attending 
the recipient receiving inpatient hos- 
pital care covered by the claim. 

5 DIAGNOSIS CODE ADMISSION DATE - The date 

on which the recipient was admitted to 
the hospital for services covered by the 
claim . 

6 BEGINNING DATE OF SERVICE 

7 ENDING DATE OF SERVICE 

8 DAYS OF STAY - Total days of hospital 

stay covered by the claim. 

9 PATIENT STATUS - An abbreviated indi- 
cation of the status of the patient as 
of the indicated ending date of service 
(e.g., RES = Still resident, DSCG = 
Discharged, etc.) 

SURGERY CODE - The procedure code of the 
primary surgical procedure rendered, if 
any, during the time period covered by 
the claim. 



10 



-154- 



2.6.5.1 CLAIM DETAIL REPORT: RECIPIENT 
REPORT CONTENT DEFINITION 
DETAIL DATA ELEMENTS (Continued) 

Reference Number Data Element Title and Description 

11 DAYS OF PREOPERATIVE STAY - Total 

days of stay prior to the date that 
surgery, if any, was rendered. 

12 TOTAL CLAIM CHARGE - The dollar amount 

charged by the hospital for services 
rendered . 

13 PERCENT OF CHARGES FOR ANCILLARY 

SERVICES - The percent of the total 
claim charge for ancillary services. 

14 PAYMENT AMOUNT 

15 PAYMENT DATE 

PRESCRIBED DRUGS 

Reference Number Data Element Title and Description 

1 PROVIDER NUMBER 

2 TRANSACTION CONTROL NUMBER 

3 TRANSACTION CODE 

4 PRESCRIBING PRACTITIONER NUMBER - The 

provider number of the practitioner who 
prescribed the drug covered by the 
claim. 

5 DIAGNOSIS CODE 

6 DATE DISPENSED - The date on which the 

drug covered by the claim was delivered 
to the recipient. 



-155- 



2.6.5.1 CLAIM DETAIL REPORT: RECIPIENT 
REPORT CONTENT DEFINITION 
DETAIL DATA ELEMENTS (Continued) 

Reference Number Data Elements Title and Description 

7 PRESCRIPTION NUMBER - A number assigned 

to the covered prescription by the 
pharmacist . 

8 DRUG CODE - A unique code identifying 

the drug dispensed. 

9 DRUG QUANTITY - The units of drug dis- 
pensed according to the unit of measure 
applicable to that drug. 

10 DAYS OF SUPPLY - The number of days over 

which the drug dispensed is to be admin- 
istered . 

11 REFILL INDICATOR - A code indicating the 

number of times the prescription has 
been refilled after the covered pre- 
scription has been dispensed. 

12 TOTAL CLAIM CHARGE 

13 AVERAGE WHOLESALE PRICE 

14 PAYMENT AMOUNT FOR DRUG - The amount 

paid for the drug exclusive of any pro- 
fessional fee. 

15 PAYMENT AMOUNT 

16 PAYMENT DATE 



-156- 



2.6.5.2 CLAIM DETAIL REPORT: PROVIDER 
PHYSICIAN SERVICES 



REPORT FORMAT EXAMPLE 
(On following page) 



-157- 



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■158- 



2.6.5.2 CLAIM DETAIL REPORT: PROVIDER 
PHYSICIAN SERVICES 
REPORT CONTENT DEFINITION 
IDENTIFICATION REPORT ITEMS 



Reference Title Report Item title 

NAME PROVIDER NAME 

NUMBER PROVIDER NUMBER 

LOCATION PROVIDER COUNTY CODE 

TYPE PROVIDER TYPE CODE 

SPECIALTY PROVIDER MEDICAL SPECIALTY CODE 

SIZE NUMBER OF PHYSICIANS IN GROUP 

DETAIL DATA ELEMENTS 

Reference Number Data Element Title and Description 

1 RECIPIENT ID NUMBER - A unique number 

assigned by the State to each Medicaid 
recipient . 

2 TRANSACTION CONTROL NUMBER 

3 TRANSACTION CODE 

4 REFERRING PHYSICIAN NUMBER 

5 RECIPIENT AGE 

6 RECIPIENT SEX 

7 TOTAL CLAIM CHARGE 

8 BEGINNING DATE OF SERVICE 

9 ENDING DATE OF SERVICE 

10 PLACE OF SERVICE 

11 DIAGNOSIS CODE 

12 PROCEDURE CODE 



-159- 



2.6.5.2 CLAIM DETAIL REPORT: PROVIDER 
PHYSICIAN SERVICES 
REPORT CONTENT DEFINITION 
DETAIL DATA ELEMENTS (Continued) 



Reference Number Data Element Title and Description 

13 UNITS OF SERVICE 

14 PROCEDURE CHARGE 

15 PAYMENT AMOUNT 

16 PAYMENT DATE 



-l6o- 



2.6.5.3 CLAIM DETAIL REPORT: PROVIDER 
INPATIENT HOSPITAL SERVICES 

REPORT FORMAT EXAMPLE 
(On following page) 



-l6l- 



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-162- 



2.6.5.3 CLAIM DETAIL REPORT: PROVIDER 
INPATIENT HOSPITAL SERVICES 

REPORT CONTENT DEFINITION 
IDENTIFICATION REPORT ITEMS 



Reference Title Report Item Title 

NAME PROVIDER NAME 

NUMBER PROVIDER NUMBER 

LOCATION PROVIDER COUNTY CODE 

TYPE PROVIDER TYPE CODE 

SPECIALTY PROVIDER MEDICAL SPECIALTY CODE 

SIZE NUMBER OF BEDS IN HOSPITAL 

DETAIL DATA ELEMENTS 

Reference Number Data Element Title and Description 

1 RECIPIENT ID NUMBER 

2 TRANSACTION CONTROL NUMBER 

3 TRANSACTION CODE 

4 ADMISSION DATE 

5 BEGINNING DATE OF SERVICE 

6 ENDING DATE OF SERVICE 

7 DAYS OF STAY 

8 PATIENT STATUS 

9 DIAGNOSIS CODE 

10 SURGERY CODE 

11 DAYS OF PREOPERATIVE STAY 

12 ATTENDING PHYSICIAN NUMBER 

13 RECIPIENT AGE 

14 RECIPIENT SEX 



-163- 



2.6.5.3 CLAIM DETAIL REPORT: PROVIDER 
INPATIENT HOSPITAL SERVICES 
REPORT CONTENT DEFINITION 
DETAIL DATA ELEMENTS (Continued) 



Reference Number Data Element Title and Description 

15 TOTAL CLAIM CHARGE 

16 PERCENT OF CHARGES FOR ANCILLARY SERVICES 

17 PAYMENT AMOUNT 

18 PAYMENT DATE 



-164- 



2.6.5.4 CLAIM DETAIL REPORT: PROVIDER 
OUTPATIENT HOSPITAL SERVICES 



-I65- 



2.6.5.4 CLAIM DETAIL REPORT: PROVIDER 



OUTPATIENT HOSPITAL SERVICES 
REPORT CONTENT DEFINITION 
IDENTIFICATION REPORT ITEMS 

Reference Title Report Item Title 

NAME PROVIDER NAME 

NUMBER PROVIDER NUMBER 

LOCATION PROVIDER COUNTY CODE 

TYPE PROVIDER TYPE CODE 

SPECIALTY PROVIDER MEDICAL SPECIALTY CODE 

DETAIL DATA ELEMENTS 

Reference Number Data Element Title and Description 

1 RECIPIENT ID NUMBER 

2 TRANSACTION CONTROL NUMBER 

3 TRANSACTION CODE 

4 REFERRING PHYSICIAN NUMBER 

5 RECIPIENT AGE 

6 RECIPIENT SEX 

7 TOTAL CLAIM CHARGE 

8 BEGINNING DATE OF SERVICE 

9 ENDING DATE OF SERVICE 

10 DIAGNOSIS CODE 

11 PROCEDURE CODE 

12 UNITS OF SERVICE 

13 PROCEDURE CHARGE 

14 PAYMENT AMOUNT 

15 PAYMENT DATE 

-166- 



2.6.5.5 CLAIM DETAIL REPORT: PROVIDER 
LONG TERM CARE FACILITY SERVICES 

« 



-I67- 



2.6.5.5 CLAIM DETAIL REPORT: PROVIDER 



LONG TERM CARE FACILITY SERVICES 
REPORT CONTENT DEFINITION 
IDENTIFICA TION REPORT ITEMS 

Report Item Title 

PROVIDER NAME 
PROVIDER NUMBER 
PROVIDER COUNTY CODE 
PROVIDER TYPE CODE 
PROVIDER MEDICAL SPECIALTY CODE 
NUMBER OF BEDS IN LTCF 

DETAIL DATA ELEMENTS 



Reference Number Data Element Title and Description 

1 RECIPIENT ID NUMBER 

2 TRANSACTION CONTROL NUMBER 

3 TRANSACTION CODE 

4 ADMISSION DATE 

5 BEGINNING DATE OF SERVICE 

6 ENDING DATE OF SERVICE 

7 DAYS OF STAY 

8 LEAVE DAYS - Total leave days for other 

than outside medical care 

9 PATIENT STATUS 

10 DIAGNOSIS CODE 

11 ATTENDING PHYSICIAN NUMBER 

12 RECIPIENT AGE 

13 RECIPIENT SEX 

-168- 



Reference Title 

NAME 
NUMBER 
LOCATION 
TYPE 

SPECIALTY 
SIZE 



2.6.5.5 CLAIM DETAIL REPORT: PROVIDER 
LONG TERM CARE FACILITY SERVICES 
REPORT CONTENT DEFINITION 
DETAIL DATA ELEMENTS (Continued) 



Reference Number Data Element Title and Description 

14 TOTAL CLAIM CHARGE 

15 PERCENT OF CHARGES FOR ANCILLARY SERVICES 

16 PAYMENT AMOUNT 

17 PAYMENT DATE 



-I69- 



2.6.5.6 CLAIM DETAIL REPORT: PROVIDER 
DENTAL SERVICES 



-170- 



2.6.5.6 CLAIM DETAIL REPORT: PROVIDER 
DENTAL SERVICES 
REPORT CONTENT DEFINITION 
I DENTIFICATION REPORT ITEMS 

Reference Title Report Item Title 

NAME PROVIDER NAME 

NUMBER PROVIDER NUMBER 

LOCATION PROVIDER COUNTY CODE 

TYPE PROVIDER TYPE CODE 

SPECIALTY PROVIDER MEDICAL SPECIALTY CODE 

SIZE NUMBER OF DENTISTS IN GROUP 

DETAIL DATA ELEMENTS 

Reference Number Data Element Title and Description 

1 RECIPIENT ID NUMBER 

2 TRANSACTION CONTROL NUMBER 

3 TRANSACTION CODE 

4 REFERRING PRACTITIONER NUMBER 

5 RECIPIENT AGE 

6 RECIPIENT SEX 

7 TOTAL CLAIM CHARGE 

8 BEGINNING DATE OF SERVICE 

9 ENDING DATE OF SERVICE 

10 DIAGNOSIS CODE 

11 PROCEDURE CODE 

12 UNITS OF SERVICE 

13 TOOTH NUMBER 

14 TOOTH SURFACE 

-171- 



2.6.5.6 CLAIM DETAIL REPORT; PROVIDER 
DENTAL SERVICES 
REPORT CONTENT DEFINITION 
DETAIL DATA ELEMENTS (Continued) 

Reference Number Data Element Title and Description 

15 PROCEDURE CHARGE 

16 PAYMENT AMOUNT 

17 PAYMENT DATE 



-172- 



2.6.5.7 CLAIM DETAIL REPORT: PROVIDER 
PRESCRIBED DRUGS 



REPORT FORMAT EXAMPLE 
(On following page) 



-173- 



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-174- 



2.6.5.7 CLAIM DETAIL REPORT: PROVIDER 



REPORT CONTENT DEFINITION 
IDENTIFICATION REPORT ITEMS 



Reference Title 

NAME 
NUMBER 
LOCATION 
TYPE 



PRESCRIBED DRUGS 



Report Item Title 



PROVIDER NAME 
PROVIDER NUMBER- 
PROVIDER COUNTY CODE 
PROVIDER TYPE CODE 

DETAIL DATA ELEMENTS 



Reference Number Data Element Title and Description 

1 RECIPIENT ID NUMBER 

2 TRANSACTION CONTROL NUMBER 

3 TRANSACTION CODE 

4 DATE DISPENSED 

5 DIAGNOSIS CODE 

6 PRESCRIBING PRACTITIONER NUMBER 

7 PRESCRIPTION NUMBER 

8 DRUG CODE 

9 DRUG QUANTITY 

10 DAYS OF SUPPLY 

11 REFILL INDICATOR 

12 RECIPIENT AGE 

13 RECIPIENT SEX 

14 NURSING HOME INDICATOR - A code indi- 
cating whether or not the recipient was 
resident in a nursing home at the time 
that the drug was dispensed. 



-175- 



2.6.5.7 CLAIM DETAIL RE PORT: PROVIDER 
PRESCRIBED DRUGS 
REPORT CONTENT DEFINITION 
DETAIL DATA ELEMENTS (Continued) 



Reference Number Data Element Title and Description 

15 TOTAL CLAIM CHARGE 

16 AVERAGE WHOLESALE PRICE 

17 PAYMENT AMOUNT FOR DRUG 

18 * PAYMENT AMOUNT 

19 PAYMENT DATE 



-176- 



2.6.5.8 CLAIM DETAIL REPORT: PROVIDER 
OTHER PROVIDER SERVICES 



-177- 



2.6.5.8 CLAIM DETAIL REPORT: PROVIDER 



OTHER PROVIDER SERVICES 
REPORT CONTENT DEFINITION 
IDENTIFICAT ION REPORT ITEMS 

Report Item Title 

PROVIDER NAME 
PROVIDER NUMBER 
PROVIDER COUNTY CODE 
PROVIDER TYPE CODE 
PROVIDER MEDICAL SPECIALTY CODE 

DETAIL DATA ELEMENTS 

Reference Number Data Element Title and Description 



1 


RECIPIENT ID NUMBER 


2 


TRANSACTION CONTROL NUMBER 


3 


TRANSACTION CODE 


4 


REFERRING PRACTITIONER NUMBER 


5 


RECIPIENT AGE 


6 


RECIPIENT SEX 


7 


TOTAL CLAIM CHARGE 


8 


BEGINNING DATE OF SERVICE 


9 


ENDING DATE OF SERVICE 


10 


PLACE OF SERVICE 


11 


DIAGNOSIS CODE 


12 


PROCEDURE CODE 


13 


UNITS OF SERVICE 


14 


PROCEDURE CHARGE 



-178- 



Reference Title 

NAME 
NUMBER 
LOCATION 
TYPE 

SPECIALTY 



2.6.5.8 CLAIM DETAIL REPORT: PROVIDER 
OTHER PROVIDER SERVICES 
REPORT CONTENT DEFINITION 
DETAIL DATA ELEMENTS (Continued) 

Reference Number Data Element Title and Description 

15 PAYMENT AMOUNT 

16 PAYMENT DATE 



-179- 



2 . 7 REQUESTED SPECIAL REPORTS 



2.7.1 Intended Usage 

Requested Special Reports may be obtained to 
satisfy requirements for information which is available 
from paid claims, but which is hot provided by standard 
S/UR reports. The procedures used to obtain the 
Requested Special Reports are intended to allow for the 
selection, manipulation and reporting of desired infor- 
mation with maximum ease and flexibility. Both the 
information content of the reports and the format for 
displaying the information may be specified in a simple 
and convenient manner. 

2.7.2 Reporting Capabilities 

Various reporting capabilities are provided to the 
user such that he has a flexible, and yet simple, means 
of specifying both the content and the format of Re- 
quested Special Reports. The capabilities which the 
user desires to exercise are entered as input specifi- 
cations to the Report Writer Module. To relieve the 
user of unnecessary rules in the formulation of his 
specifications, the specifications may be entered in a 
free-format and almost order- independent manner. The 
user specifications are processed by the Report Writer 
Module in four steps. 

The first step reads and edits the specifications 
for correctness. If each specification is consistent 
with the rules for formulating specifications, it is 
simply listed, otherwise an appropriate diagnostic 
message is listed along with the offending specifica- 
tions. If all specifications are correct and consis- 
tent, a dummy report is constructed according to the 
user's specifications and is listed. This dummy report 
is provided to allow the user an opportunity to inspect 



-180- 



the format of the report before any further processing 
takes place. The correct specifications are forwarded 
to subsequent steps. 

The second step uses the content specifications 
dictated by the user to accumulate all information 
from each claim necessary for selection and reporting 
purposes. The necessary information may be obtained 
from one of four sources: (1) from the available paid 
claim data itself, (2) from the claim's associated Pro- 
vider Master File data, (3) from the claim's associated 
Medicaid Eligibility Master File data, and (4) from 
results computed according to user specified arithmet- 
ical expressions. An example of an arithmetical 
expression would be to compute the service period of a 
claim by subtracting the Beginning Date of Service from 
the Ending Date of Service. After obtaining the neces- 
sary data, this step selects those claims which the 
user specifies as acceptable for reporting purposes. 
A claim's acceptability is computed according to a user 
specified logical expression. An example of a logical 
expression might be to select only those claims whose 
service period is over ten days and whose Ending Date 
of Service is in the current year. Thus, only selected, 
acceptable claims are passed to the next step. 

The third step allows the user to order the select- 
ed claims, along with their augmented information, into 
a specific order for reporting purposes. This step is 
optional and would be required only if the order of the 
selected claims were unsatisfactory for reporting pur- 
poses. The claim's original order, from major to minor 
key, is sequenced by Provider Number, Category of Ser- 
vice, Recipient Identification Number, First Date of 
Service, Last Date of Service, and Claim Transaction 
Control Number. 

The final step reports the selected and ordered 

-181- 



claim information according to a user specified format. 
The user may specify the content and format of report 
headings, page headings and control headings. The 
headings will be inserted automatically where appro- 
priate and are governed by user dictated report breaks 
page breaks, and control breaks. The user may specify 
the content and format of each element of the detail 
line. If total lines are desired, the totals are auto- 
matically accumulated for each control break for the 
elements specified by the user and automatically in- 
serted at the control break according to the format 
specified by the user. Also, a control footing may be 
specified and will be inserted automatically at each 
control break and after the total line. The control 
footing is a combination of heading and computational 
data. The heading or description data is user speci- 
fied and is reported along with a computed result. The 
computation is user specified and is computed from an 
arithmetic expression. This facility allows for com- 
puting basic statistics for each control group. 

2.7.3 Organization and Format 

The user may organize his Requested Special Reports 
as he desires. The third step of the Reporting Logic 
allows the user to order the selected claims according 
to his own criteria. This will enable him to group or 
organize the elements of the report to the extent that 
he can group or organize the selected claims. 

The basic format for a report is under user con- 
trol. Report, page and control headings are automati- 
cally inserted, if they are specified. A detail line 
corresponds to a selected claim and its associated 
information. Each selected claim's information contri- 
butes equally to each of a subtotal or total line and 
a statistic line, which are automatically inserted 



-I82- 



after control breaks where specified. A detail line 
need not be printed if the user does not desire it, but 
at least one of the detail line, total line or statis- 
tics line must be specified for printing. 

2.7.4 General Description of Content 

The content of any Requested Special Report is 
generally under the control of the user. The user may 
select up to fifty elements from the information avail- 
able from the Claims History File, the Provider Master 
File, the Medicaid Eligibility Master File, or any 
arithmetical, relational or logical combination of them. 
These elements may then be used in the detail lines, 
total lines or statistics lines to be printed in the 
report . 

2.7.5 Data Base Definition 

The following pages contain file definitions and 
file descriptions for each of the three major files from 
which data is available to create Requested Special 
Reports. Definitions for each Data Element contained in 
these files may be found in Volume V of the MMIS General 
System Design documentation. 



-I83- 



MFD I CA ID MANAGEMENT INFORMATION SYSTEM 
S/UR OPERATIONAL TECHNIQUES 



2.7.5.1 



FILE DEFINITION 



F i Lt NAME 



FILE NO. 



PROVIDER MASTER FILE 



PS F-01 



S UBSYSTE M N A Mb J 



T 



PROVIDER SUBSYSTEM 



8/1/71 



r 



t v n r 
II r l 



PROVIDER NUMBER 



LI 



E DP 



MAN UA,i_ 



UPDATE PROCEDURE" | 

Update daily if transactions are present. 

PURPOSE AN D FUNCTION \ 

To retain provider related data to be used by the Claims 
Processing, Management and Administrative Reporting, and Surveillance 
and Utilization Review subsystems. 

To provide a data base for maintenance, control, and efficient 
retrieval of information relating to providers. 



REM ARKS 1 



-184- 



PAGE x OF x 



MEDICAID MANAGEMENT INFORMATION SYSTEM 
S/UR OPERATIONAL TECHNIQUES 

2.7.5.1 (cont) F I I. F DESCRIPTION 


FILE NAME 1 
PROVIDER MASTER FILE 


F 1 1 F NO . 1 

PS-F-01 


SUBSYSTEM NAME 


DAT F 1 
— - — i 




PROVIDE 

h ■ — 


R SUBSYSTEM 


8/1/71 


CT 1 CMCMT 

L_ I_ 1_ 1 1 L_ 1 1 | 

NO. 


DATA ELEMENTS ^Vm?!^ 0 "" 

MI N IMAL — ^ 4- 


201 


Provider Number 


X 




202 


Provider Name 


X 




203 


Provider Address 


X 




204 


Provider Pay to Address 




X 


205 


Provider Type 


X 




i 

[ 301 | Category of Service 




X 





207 


Beginning Date of Service 


X 




208 


Ending Date of Service 


X 






(data elements 301 and 207 through 208 are repeated 








up to 10 times) 






209 


Provider Group Number 




X 


210 


Provider Type of Practice Organization 




X 


211 


Provider County Code 


X 




2JL2 


Provider Employer Identification Number 


X 




213 


Provider Social Security Number 


X 




214 


Medicare Provider Number 




X 


215 


Provider Medicare Reimbursement Rates 




X 


216 


Provider Year End Date 




X 


217 


Provider License Number 




X 


218 


Provider License Board Code 




X 


219 


Provider License Date 




X 


220 


Provider Specialty Code 


X 




221 


Specialty Certification Number 




X 


222 


Specialty Certification Board Code 




X 


223 


Specialty Certification Date 




X 




fdata elements 220 through 223 are repeated up to 







-185- 



PAGE 2 CP 2 



2.7.5.1 (cont) 



MEDICAID MANAGEMENT INFORMATION SYSTEM 
S/UR OPERATIONAL TECHNIQUES 

F I I F 11 F S C R I P T I n M 



Flip NAME 



PROVIDER MASTER FILE 



SIJ BS YS T-EM NAMf , I 

PROVIDER SUBSYSTEM 



F f I I NO 



PS-F-01 



D A T F 



8/1/71 



IT I CMCMT 

L_ LLI Il_M I 

In U . 


. _ . _, RECOMMENDED 1 

DATA ELEMENTS mtmt^ai 

MINIMAL yv 1 


three times) 






2 24 

£i L t 


Date of Last Transaction 




X 


2 2 S 

L, Lf mJ 


Provider Exception Indicator 




X 


? ? f\ 


Provider Credit Balance Amount 


X 




2 2 7 


Provider Credit Balance Date 


X 




1 

? 2 


Provider Application Date | x 


22Q 

Li Li V 


Provider Rejection Reason Code 




X 


2 30 

u 


Out of State Provider Code 




X 


z 3 1 


National Pharmacy Number 




X 


L O L 


Number of Beds Certified 




X 


L D J 


Per Diem Rate 


X 






Percent of Charges Factor 






235 


Rate Effective Date 


X 






(data elements 233 through 235 are repeated up to 








five times) 






236 


Provider Location Code 




X 


237 


Control of Medical Facility 




X 


238 


Provider Enrollment Status Code 


X 




239 


Provider Enrollment Status Date 


X 






(data elements 238 and 239 are repeated up to five 








times) 


— 1 




241 


Number Physicians in Group 




X 






1 


— — 1 













i 






r 





-186- 



MEDICAID MANAGEMENT INFORMATION SYSTEM 
S/UR OPERATIONAL TECHNIQUES 



2.7.5.2 



FILE DEFINITION 



F I LE NAME 1 



FILE NO. 



MEDICAID ELIGIBILITY MASTER FILE 



RS-F-01 



SUBSYSTEM NAME | ' 



DATE I 



RECIPIENT SUBSYSTEM 



8/1/71 



SEQUENCE 1 



FILE TYPE 



RECIPIENT IDENTIFICATION NUMBER 



IxJ 



L_l 



ED 



. UPDATE PROCEDUr.. 
Updated daily 



PURPOSE AND FUNCTION 



The Medicaid Eligibility Master File contains one record for 
each Medicaid recipient who is eligible now or has been eligible 
during the past five years. This file contains all data items con- 
cerning individual recipients which are needed for claims payment 
and other related Medicaid activities. This file is updated every 
day that there are new eligibility transactions to process or 
eligibility errors to correct. 



REMARKS j 



-187- 



1 or jl 





MFD T PA IF) MA f'Af-FMFMT INFORMATION CV^TFM 










S/UR OPERATIONAL TECHNIQUES 








2.7.5.2 (c 


v Clip n r C f D | p T I n fl 
ont) ' ' ' i i j r. o \. r\ i r i I ij i« 








FILE NAME 




F I 1 F NO 


.1 




MEDICAID ELIGIBILITY MASTER FILE 


RS-F-01 






SUBSYSTEM 


NAME 1 


OAT F 1 

ZZ 1 






RECIPIENT SUBSYSTEM 


8/1/71 








CI C M C-" M T 

U. LL.I IUH 1 

N 0 . 


DATA ELEMENTS 


M INI M A L M- 


1 


101 


Recipient Identification Number 


X 




102 


Social Security Claim Number 


x 




103 


Recipient Name 


X 




104 


Recipient Address 


x 




105 


Recipient Date of Birth 


x ! 


1 

106 


Recipient Race Code 




X 


1 


107 


Recipient Sex Code 


X 




108 


Recipient County Code 


X 




109 


Recipient Aid Category 


X 




110 


Eligibility Begin Date 


X 




111 


Eligibility End Date 


X 






(data elements 108 through 111 are repeated ten times) 






112 


Date of Death 


X 




113 


Third Party Liability Code 


X 




114 


Buy- In Status Code 


X 




115 


Date of Last Transaction 




X 


116 


Recipient Exception Indicator 




X 


117 


Money Payment Code 


X 




118 


Medicare Type Code 




X 


121 


Identification Card Indicator 




X 


122 


Date of Identification Care Issue 




X 




(data element 122 is repeated five times) 






123 


Buy-In Eligibility Date 


X 




124 


Scope of Coverage Code 




X 


132 


Recipient Approval for Assistance Date 




X 


133 


- - ■■■ ■ ■- 

Recipient Location Code 




X 



-188- 



MEDICAID MANAGEMENT INFORMATION SYSTEM 
S/UR OPERATIONAL TECHNIQUES 




2753 FILE DEFINITION 




FI LE NAME I 


FILE NO. | 


CLAIMS HISTORY FILE 


SU-F-05 


SUBS v S i EM NAME J 


_ . _ _ i 

UA 1 t 1 


SURVEILLANCE AND UTILIZATION REVIEW 


8/1/71 


SEQUENCE | 


i - t i c- tv nr 
I l i i r i_ 


INDEXED BY PROVIDER NUMBER AND RECIPIENT NUMBER 


i i 

EDP MANUAL 


UPDATE PROCEDURE | 




The Claims History File is updated monthly with data from the Adjudi- 
cated Claims File. 



PURPOSE AND FUNCTION 1 



The Claims History File maintains within the Surveillance and 
Utilization Review Subsystem, a record of all claims paid by the 
claims Processing Subsystem during the last twelve months. 



REMARKS j 

The Claims History File is indexed to the Provider History File 
and the Recipient History File for identification and demographic 
data . 



-I89- 



page: jl cf 2 



MEDICAID MANAGEMENT INFORMATION SYSTEM 
S/UR OPERATIONAL TECHNIQUES 



2.7.5.3 (cont) 



F TIF DESCRIPTION 



F 1 LE NAME I 



F I I F NO 



CLAIMS HISTORY FILE 



SU-F-05 



SUBSYSTEM N A M E 



DAT F 



SURVEILLANCE AND UTILIZATION REVIEW 



8/1/71 



E 1 E MEN" 1 " 
NO . 

300 


DATA ELEMENTS " ^ » " | 

f v i i in i hA L M- v 


Transaction Control Number 


X 




301 


Category of Service 


X 




302 


Transaction Code 


X 




101 


Recipient ID Number 


X 




303 

— , — — 


Attending Physician Number 


X 




304 


Referring Physician Number j x 


1 

1 


306 


Primary Diagnosis Code 


X 


! 


307 


Secondary Diagnosis Code 


X 




201 


Provider Number 


X 


1 


349 


Payment Amount 


X 


J 


310 


Billing Date 


X 




321 


Total Claim Charge 


X 




328 


Third Party Liability Action 


X 




329 


Third Party Payment Amount 


X 




500 


Procedure Code 


X 




501 


Drug Code 


X 




315 


Refill Indicator 


X 




311 


Admission Date 


X 




312 


Beginning Date of Service 


X 




313 


Ending Date of Service 


X 




316 


Patient Status 


X 




317 


Discharged Patient's Destination 




X 


318 


Destination Provider Number 




X 


319 


Previous Provider Number 




X 


326 


Blood Not Replaced 


X 




322 


Procedure Charge 


X 


i 



-190- 



PAGE .2 OF 2 



MEDICAID MANAGEMENT INFORMATION SYSTEM 
S/UR OPERATIONAL TECHNIQUFS 

2.7.5.3 (cont) FILE DESCRIPTION 


FI LE NAME 1 

CLAIMS HISTORY FILE 


F I 1 F NO . 1 

SU-F-05 


SUBSYSTEM NAME 1 


DAT F 1 




SURVEILLANCE AND UTILIZATION REVIEW 


1— Z- 1 

8/1/71 


CI CMCMT 
INAJ ■ 

7 *1 T 

323 


i— i a -T- « r— i riiritTP RECOMMENDED i 
DATA ELEMENTS ....,„.,, 

MINIMAL * * 


Drug Tharpp 


x 




i n c 


Prescribing Physician Number 


X 






Place of Service 


X 




X 9 7 


Units of Service 


X 




x x n 


Medicare Cash Deductible Amount 


X 






j j 1 


Medicare Blood Deductible Amount x 


1 


*J J 


Medicare Coinsurance Amount 


X 




^76 


Payment Date 


X 






Adjudication Status 


X 




378 


Date of Surgery 


X 




379 


Leave Days 


X 




380 


Allowable Procedure Payment 


X 




381 


Professional Fee 


X 




503 


Maximum Days Supply of Drug 


X 




384 


Type of Service 


X 




233 


Per Diem Rate 


X 




386 


Prescription Number 


X 













































































-191- 



AREAS OF EXCEPTIONAL UTILIZATION 



-192- 



3. AfiBAS :6F«<5El>Tl<3WftL UTILIZATION 

3.1 INTRODUCTION 

Exceptional use of the Medicaid. Program stems from a 
variety of complex reasons and motivations. It may "be caused 
either by providers or recipients. For either, it can occur with 
fraudulent intent, hut more often as a matter of circumstance 
with no malice intented. 

Thus, the requirements for surveillance and utilization 
review and for referring situations of alleged fraud are very 
closely related-actually parts of a continuum. More specifi- 
cally, provider fraud in Medicaid occurs when a provider will- 
fully obt ains payments for a service he did not provide, and 
recipient fraud occurs when an ineligible person receives materials 
to be used by others. Other provider ahuses of Medicaid, no 
doubt much greater in volume and importance, occur when the medi- 
cal services paid are in excess of those required, do not corre- 
spond with diagnosis, are insufficient to accomplish their pur- 
pose, or are otherwise of low quality. Recipient abuses occur 
most often when medical personnel and facilities are used to 
meet non -medical needs; when duplicate services are obtained; and 
when recipients are uncooperative in accepting treatment plans. 

Examples of factors sometimes associated with recipient 
misuse of Medicaid include the following: 

1. Use of contacts with medical professionals and with 
persons in the waiting rooms of practitioners and outpatient 



-193- 



facilities for essentially social purposes; relief of 
loneliness, reassucance, aa^sul^tifcute pf,<^r.,j^<?re rr fageningful 
social activities. 

2. Recipients with impaired mental health (diagnosed or 
undiagnosed) may inappropriately seek care from physicians 
in general practice which would more appropriately he 
provided by specialists or in mental health facilities. 

3. Recipients may he dissatisfied with medical care pro- 
vided or be inconvenienced and seek duplicative care in 
more congenial quarters. 

k. Identification cards or other evidence of eligibility 
may be lent to relatives or friends who have not been 
certified as eligible. 

5. Negligence in caring for durable items - glasses, 
hearing aids, dentures, etc., as well as desire to keep up 
with rads of styling. 

6. Manipulation of the program to acquire drugs or supplies 
for ineligible persons or to be sold for personal gain. 

7. Acquisition of drugs to support narcotics addiction. 

8„ Gullibility in responding to promotional efforts or 
suggestions of practitioners that they receive care or 
supplies for which they previously had no desire and are 
unlikely to use. 



-194- 



Factors associated with provider generated misuse of 
the Medicaid program include: 

1. Inordinate referral to practitioners or facilities 
with which the referring practitioner has a financial 
arrangement or interest (e.g. ownership interest in 
institutional facilities, pharmacies, and laboratiories 
etc . ) 

2. Desire to safeguard against malpractice suits by 
"over-treating" patients and overutilizing consultants to 
avoid charges of negligence. 

3. Desire to amortize rapidly expensive equipment and 
facilities . 

4. Provision of services for training purposes. 

5. Need to maintain an adequate patient census in in- 
stitutions . 

6. Use of institutional facilities for care suitable to 
office treatment or other forms of ambulatory care. 

7. Promotional and sales efforts to provide services for 
which recipients felt no need and which they would be un- 
likely to use properly - this sometimes happens with 
dentures, hearing aids, and other prosthetic appliances. 

8. An unstructured system for the delivery of medical care 
which results in duplicate or repetitive provision of ser- 
vices instead of transfer of medical records. 

-195- 



9. Eccentric patterns of patient care. 

10. Lack of sufficient medical resources (includes no 
appropriate less expensive alternatives for medical care). 



-196- 



3.2 INDICATORS OF EXCEPTIONAL UTILIZATION 



The following charts are intended to correlate specific 
areas of potential exceptional utilization of the Medicaid 
Program to the specific report items from Summary Profile and 
Treatment Analysis Reports which are indicative of those areas. 
Only those areas of exceptional utilization which are classified 
as being specifically indicated by reports or generally in- 
dicated by reports and included in the charts. One chart or 
set of charts is included for recipients and for each of the 
six major provider categories of service for which Summary 
Profile Reports are defined in Chapter 2. 

The left hand column of each chart contains titles of each 
area of exceptional utilization covered. Most of these titles 
are sufficient to define the areas of exceptional utilization, 
however, where necessary more comprehensive definitions are 
included. The right hand column of each chart contains the 
report items from Summary Profile and/or Treatment Analysis 
Reports which are intended to reveal each area of exceptional 
utilization. Following each report item is an indication of 
the relative magnitude (high or low) of the value of that 
report item which will indicate potential exceptional utili- 
zation. Except where noted, all report items are contained 
in the Summary Profile and/or Treatment Analysis Report with 
the same title as that of the chart in which they are listed. 

Instances of probable misuse of Medicaid which usually re- 
quire minimal investigatory activity are designated in the 
following presentation as "Specially Indicated by Reports". 
Instances of possible misuse of Medicaid which will likely re- 
quire substantial investigatory activity before judgment can 
be made are designated as "Generally Indicated by Reports". 



-197- 



3.2.1 



INDICATORS OF CXCFPTIONAL UTILIZATION 



RECIPIENTS 


SPECIFICALLY INDICATED BY REPORTS 


AREA OF EXCEPTIONAL UTILIZATION 


INDICATORS OF EXCEPTIONAL UTILIZATION 


1. DOCTOR SHOPTING: 

Instances of excessive visitation to many 
physicians or other practitioners. 


SUMMARY PROFILE REPORT 

NUMBER OF DIFFERENT PHYSICIANS (HIGH) 
PERCENT INITIAL VISITS (HIGH) 


2. EXCESSIVE MEDICAL VISITS: 


SUMMARY PROFILE REPORT 




NUMBER OF MEDICAL VISITS (HIGH) 


3. DRUG OVERUTIL1ZATION: 


SUMMARY PROFILE REPORT 


Instances of excessive drug acquisition 
usually resulting from a recipient seeing 
many different physicians or other pre- 
scribing practitioners. 


NUMBER OF DRUG PRESCRIPTIONS (HIGH) 

NUMBER OF DIFFERENT DRUGS (HIGH) 

NUMBER OF ADDICTIVE DRUG PRESCRIPTIONS (HIGH) 

PERCENT REFILL PRESCRIPTIONS (HIGH) 


4. EXCESSIVE ACQUISITION OF PROSTHETIC DEVICES 


SUMMARY PROFILE REPORT 


AND EYEGLASSES: 

Instances of excessive acquisition of prosthetic 
devices and eyeglasses usually resulting from 
recipients seeing many different physicians or 
other prescribing practitioners. 


NUMBER OF PROSTHETIC DEVICES 5 EYEGLASSES (HIGH) 


5. EXCESSIVE DENTAL EMERGENCIES: 


SUMMARY PROFILE REPORT 


Instances of excessive visitations to 
dentist for emergencies. This usually 
occurs in States where the dental program 
is limited and often is a result of cir- 
cumvention of a prior authorization require- 
ment of the State. 


NUMBER OF DENTAL SERVICES (HIGH) 

NUMBER OF DENTAL EMERGENCIES (HIGH) 

RATIO OF DENTAL EMERGENCIES TO SERVICES (HIGH) 


6. EXCESSIVE TRANSPORTATION UTILIZATION: 


SUMMARY PROFILE REPORT 




NUMBER OF TRANSPORTATION SERVICES (HIGH) 


7. EXCESSIVE OPTOMFTRIC SERVICES: 


SUMMARY PROFILE REPORT 




NUMBER OF OPTOMETRIC SERVICES (HIGH) 


8. EXCESSIVE PODIATRY SERVICES: 


SUMMARY PROFILE REPORT 




NUMBER OF PODIATRIC SERVICES (HIGH) 



-198- 



3.2.2 



INDICATORS OF EXCEPTIONAL UTILIZATION 



PHYSICIAN SERVICES 


SPECIFICALLY INDICATED BY REPORTS 


ARFA OF EXCEPTIONAL UTILIZATION 


INDICATORS OF EXCEPTIONAL UTILIZATION 


1. EXCF.SSIVF. OR INSUFFICIENT VISITS TO PATIENTS 


SUMMARY PROFILE REPORT 


CONFINED- IN HOSPITALS: 


RATIO OF INPATIENT HOSPITAL VISITS TO DAYS STAY 

(HIGH OR LOW) . 
AVERAGE NUMBER OF INPATIENT HOSPITAL VISITS PER 

KtLJPIhNi (HIGH OR LOW) 


2. EXCESSIVE OR INSUFFICIENT VISITS TO PATIENTS 


SUMMARY PROFILE REPORT 


CONFINED TO NURSING HOMES: 


RATIO OF LTCF VISITS TO DAYS STAY (HIGH OR LOW) 
AVERAGE NUMBER OF LTCF VISITS PER RECIPIENT 
(HIGH OR LOW) 


3. EXCESSIVE OFFICE VISITS PER RECIPIENT: 


SUMMARY PROFILE REPORT 




AVERAGE NUMBER OF OFFICE VISITS PER RECIPIENT 
(HIGH) 

TREATMENT ANALYSIS REPORT 
AVERAGE NUMBER OF PHYSICIAN PROCEDURES PER 
RECIPIENT - BY AGE GROUP WITHIN DIAGNOSIS (HIGH) 


4. EXCFSSIVE -HOME VISITS PER RECIPIENT: 


SUMMARY PROFILE REPORT 




AVERAGE NUMBER OF HOME VISITS PER RECIPIENT (HIGH) 

TREATMENT ANALYSIS REPORT 
AVERAGE NUMBER OF PHYSICIAN PROCEDURES PER RECIP- 
IENT - BY AGE GROUP WITHIN DIAGNOSIS (HIGH) 


S. EXCESSIVE OUTPATIENT OR EMERGENCY ROOM VISITS: 


SUMMARY PROFILE REPORT 




AVERAGE NUMBER OF OUTPATIENT HOSPITAL VISITS PER 
RECIPIENT (HIGH) 

TREATMENT ANALYSIS REPORT 
AVERAGE NUMBER OF PHYSICIAN PROCEDURES PER RECIP- 
IENT - BY AGE GROUP WITHIN DIAGNOSIS 


6. UNUSUAL PRESCRIBING PRACTICES: 


SUMMARY PROFILE REPORT 




RATIO OF DRUG PRESCRIPTIONS TO VISITS (HIGH) 
RATIO OF DRUG PRESCRIPTIONS TO RECIPIENTS SERVED 
(HIGH) 

PERCENT COMPOUNDED DRUG PRESCRIPTIONS (HIGH) 
PERCENT ADDICTIVE DRUG PRESCRIPTIONS (HIGH) 
PERCENT OTC DRUG PRESCRIPTIONS (HIGH) 

TREATMENT ANALYSIS REPORT 
AVERAGE NUMBER OF DRUG PRESCRIPTIONS PER RECIPIENT - 

BY AGE GROUP WITHIN DIAGNOSIS (HIGH) 
NUMBER OF DIFFERENT DRUGS - BY AGE CROUP WITHIN 

DIAGNOSIS (HIGH) 



-199- 



3.2.2 (cont) 



INDICATORS OF FXCFPTIONAL UTILIZATION 



PHYSICIAN SERVICES (CONT) 


SPECIFICALLY INDICATED BY REPORTS 


AREA OF EXCEPTIONAL UTILIZATION 


INDICATORS OF EXCEPTIONAL UTILIZATION 


7. UNUSUAL DIAGNOSTIC PROCEDURES: - 


SUMMARY PROFILE REPORT 




RATIO OF LABORATORY PROCEDURES TO RECIPIENTS 
(HIGH) 

RATIO OF LABORATORY PROCEDURES TO VISITS (HIGH) 

RATIO OF DIAGNOSTIC RADIOLOGY PROCEDURES TO 
RECIPIENTS (HIGH) 

RATIO OF DIAGNOSTIC RADIOLOGY PROCEDURES TO 
VISITS (HIGH) 

RATIO OF OTHER DIAGNOSTIC PROCEDURES TO RECIP- 
IENTS (HIGH) 

RATIO OF OTHER DIAGNOSTIC PROCEDURES TO VISITS 
(HIGH) 

TREATMENT ANALYSIS REPORT 

AVERAGE NUMBER OF PHYSICIAN PROCEDURES PER RECIP- 
IENT - BY AGE GROUP WITHIN DIAGNOSIS (HIGH) 

NUMBER OF DIFFERENT PHYSICIAN PROCEDURES - BY AGE 
GROUP WITHIN DIAGNOSIS (HIGH) 


8. EXCESSIVE SURGERY PER RECIPIENT: 


SUMMARY PROFILE REPORT 




KA 1 i U Ur jUKulLAL rKULCUUKto 1U KtLlrlLiNlo ^nlUnJ 

TREATMENT ANALYSIS REPORT 

AVERAGE NUMBER OF PHYSICIAN PROCEDURES PER RECIP- 
IENT - BY AGE GROUP WITHIN DIAGNOSIS (HIGH) 

NUMBER OF DIFFERENT PHYSICIAN PROCEDURES - BY 
AGE GROUP WITHIN DIAGNOSIS (HIGH) 


• 9. FREQUENT DELAYED SURGERY: 


SUMMARY PROFILE REPORT 


Instances of excessively high average days of 
preoperative stay per incident of surgery 
when the surgeon is compared to his peers. 


AVERAGE DAYS OF PREOPERATIVE STAY (HIGH) 


10. EXCESSIVE INJECTIONS PER RECIPIENT: 


SUMMARY PROFILE REPORT 




RATIO OF OFFICE INJECTIONS TO OFFICE VISITS (HIGH) 
RATIO OF INJECTIONS TO RECIPIENTS (HIGH) 


- 

11 UMIKIIAT TN9T I TUT Tf)\'A 1 AElMT 99 TOV PRAfTIfFS - 


SUMMARY PROFILE REPORT 


Instances of excessively high or low number of 
institutional confinements per recipient by 
a physician as compared to his peers. 


RATIO OF HOSPITAL DISCHARGES TO RECIPIENTS (HIGH) 
RATIO OF LTCF PATIENTS TO RECIPIENTS (HIGH) 

TREATMENT ANALYSIS REPORT 
AVERAGE NUMBER OF HOSPITAL DISCHARGES PER RECIP- 
IENT - BY AGE GROUP WITHIN DIAGNOSIS (HIGH) 


12. UNUSUAL LENGTH OF HOSPITAL STAY: 


SUMMARY PROFILE REPORT 




AVERAGE DAYS STAY PER HOSPITAL DISCHARGE (HIGH) 

TREATMENT ANALYSIS REPORT 
AVERAGE DAYS STAY PER HOSPITAL DISCHARGE - BY 
AGE GROUP WITHIN DIAGNOSIS (HIGH) 



-200- 



3.2.2 (cont) 



INDICATORS OF EXCEPTIONAL UTILIZATION 



PHYSICIAN SERVICES (CONT) 


SPECIFICALLY INDICATED BY REPORTS 


AREA OF EXCEPTIONAL UTILIZATION ... . 


INDICATORS OF EXCEPTIONAL UTILIZATION 


13. UNDER UTILISATION OF LTCF AND HOME CARE ACENCIES: 


SUMMARY PROFILE REPORT 


Instances of extended hospital confinement where 
use of long term care facilities or home health 
agencies is indicated. 


PERCENT DISCHARGES TO LTCF (LOW) 
PERCENT DISCHARGES TO HOME CARE (LOW) 


GENERALLY INDICATED BY REPORTS 


AREA OF EXCEPTIONAL UTILIZATION 


INDICATORS OF EXCEPTIONAL UTILIZATION 


1. EXCESSIVE REFERRAL TO SPECIALISTS: 


SUMMARY PROFILE REPORT 




RATIO OF SERVICES OF OTHER PHYSICIANS TO RECIP- 
IENTS (HIGH) 

RATIO OF OTHER PHYSICIAN REFERRALS TO RECIP- 
IENTS (HIGH) 


2. GANG VISITS: 

Frequent instances of multiple visits on a single 
day to many recipients at the same facility or 
location. 


SUMMARY PROFILE REPORT 
MAXIMUM HOME VISITS IN ONE DAY (HIGH) 
MAXIMUM INPATIENT HOSPITAL VISITS IN ONE DAY (HIGH) 
MAXIMUM LTCF VISITS IN ONE DAY (HIGH) 



-201- 



3.2.3 



INDICATORS OF EXCEPTIONAL UTILIZATION 



INPATIENT HOSPITAL SERVICES 


SPECIFICALLY INDICATED BY REPORTS 


AREA OF EXCEPTIONAL UTILIZATION 


INDICATORS OF EXCEPTIONAL UTILIZATION 


1. FREQUENT FRIDAY- SATURDAY ADMISSION AND/OR SUNDAY- 


SUMMARY PROFILE REPORT 


MONDAY DISCHARGE: 

Instances of inappropriate hospital confinement over 
weekend periods. 


PERCENT FRIDAY- SATURDAY ADMISSIONS (HIGH) 
PERCENT SUNDAY - MONDAY DISCHARGES (HIGH) 


2 EXTENDED CONFINEMENT RY DT AHNO^ T C^nRfiTrA! 


TREATMENT ANALYSIS REPORT 


AND NON-SURGICAL) : 

Instances of hospital confinement of durations 
inappropriate to specific diagnoses. 

• 


AVERAGE NUMBER OF DAYS STAY PER SURGICAL DIS- 
CHARGE-BY AGE GROUP WITHIN DIAGNOSIS (HIGH) 

AVERAGE NUMBER OF DAYS STAY PER NON-SURGICAL DIS- 
CHARGE-BY AGE GROUP WITHIN DAIGNOSIS (HIGH) 


3. EXCESSIVE ANCILLARY SERVICE CHARGES: 


SUMMARY PROFILE REPORT 




PERCENT PAYMENTS FOR ANCILLARY SERVICES (HIGH) 
AVERAGE ANCILLARY PAYMENT PER DISCHARGE (HIGH) 

TOPATMCWT AMiT YQTQ OPDOOT 
1 KEA I MEN 1 ANAL 1515 KE rUR 1 

PERCENT OF CHARGES FOR ANCILLARY SERVICES WITH 

SURGICAL DISCHARGE -BY AGE GROUP WITHIN 

DIAGNOSIS (HIGH) 
PERCENT OF CHARGES FOR ANCILLARY SERVICES WITH 

NON- SURGICAL DISCHARGE-BY AGE GROUP WITHIN 

DIAGNOSIS (HIGH) 


4. FREQUENT DELAYED SURGERY PER RECIPIENT: 


SUMMARY PROFILE REPORT 


Instances of excessive hospital confinement prior 
to surgery. 


I 

AVERAGE DAYS OF PREOPERATIVE STAY (HIGH) 

t 


GENERALLY INDICATED BY REPORTS 


AREA OF EXCEPTIONAL UTILIZATION 


INDICATORS OF EXCEPTIONAL UTILIZATION 


1. EXCESSIVE ONE OR TWO DAY DIAGNOSTIC 


SUMMARY PROFILE REPORT 


CONFINEMENTS: 


PERCENT DISCHARGES 1 DAY (HIGH) 
PERCENT DISCHARGES 2 DAYS (HIGH) 


2. UNDEP.UTILIZATION OF LTCF AND/OR HOME CARE AGENCIES: 


SUMMARY PROFILE REPORT 


Instances of extended hospital confinement where use 
of long term care facilities or home care agencies 

is indicated. 


AVERAGE STAY PER DISCHARGE (HIGH) 
PERCENTAGE DISCHARGES TO LTCF (LOW) 
PERCENTAGE DISCHARGES TO HOME CARE (LOW) 



-202- 



3.2.4 INDICATORS OF EXCEPTIONAL UTILIZATION 





OUTPATIENT HOSPITAL 


SERVICES 




SPECIFICALLY INDICATED 


BY REPORTS 


AREA OF EXCEPTIONAL UTILIZATION 


INDICATORS OF EXCEPTIONAL UTILIZATION 


1 . 


EXCESSIVE OUTPATIENT OR EMERGENCY ROOV VISITS: 




SUMMARY PROFILE REPORT 








AVERAGE NUMBER OF VISITS PER RECIPIENT (HIGH) 


7 . 


UNUSUAL PRESCRIBING PRACTICES: 




SUMMARY PROFILE REPORT 








RATIO OF DRUG PRESCRIPTIONS TO VISITS (HIGH) 








RATIO OF DRUG PRESCRIPTIONS TO RECIPIENTS (HIGH) 








PERCENT COMPOUNDED DRUG PRESCRIPTIONS (HIGH) 








PERCENT ADDICTIVE DRUG PRESCRIPTIONS (HIGH) 








PERCENT OTC DRUG PRESCRIPTIONS (HIGH) 


3. 


UNUSUAL DIAGNOSTIC PRACTICES: 




SUMMARY PROFILE REPORT 








RATIO OF LABORATORY PROCEDURES TO RECIPIENTS (HIGH) 








RATIO OF LABORATORY PROCEDURES TO VISITS (HIGH) 








RATIO OF DIAGNOSTIC RADIOLOGY PROCEDURES TO 








RECIPIENTS (HIGH) 








RATIO OF DIAGNOSTIC RADIOLOGY PROCEDURES TO VISITS 








(HIGH) 








RATIO OF OTHER DIAGNOSTIC PROCEDURES TO RECIPIENTS 








(HIGH) 








RATIO OF OTHER DIAGNOSTIC PROCEDURES TO VISITS 






— 


(HIGH) 


4 . 


EXCESSIVE INJECTIONS PER RECIPIENT: 




SUMMARY PROFILE REPORT 








RATIO OF INJECTIONS TO VISITS (HIGH) 








RATIO OF INJECTIONS TO RECIPIENTS (HIGH) 


5. 


EXCESSIVE REFERRAL TO SPECIALISTS: 




SUMMARY PROFILE REPORT 








RATIO OF SERVICES OF SPECIALISTS TO RECIPIENTS 








(HIGH) 








RATIO OF REFERRALS TO RECIPIENTS (HIGH) 



-203- 



3.2.5 



INDICATORS OF EXCFPTIONAL UTILIZATION 



LONG TERM CARE FACILITY SERVICES 



SPECIFICALLY INDICATED BY REPORTS 



AREA OF EXCEPTIONAL UTILIZATION 



INDICATORS OF EXCEPTIONAL UTILIZATION 



INAPPROPRIATE l.TNCTHS OF STAY : 

Lengths of stay inappropriate to level of care 
provided (SNII, ECF, ICF, etc.). 



SUMMARY PROF 1 1, F. REPORT 

AVERAGE DAYS STAY PER RESIDENT (HIGH OR LOW) 
AVERAGE LEAVE DAYS PER RESIDENT (HIGH) 
AVERAGE DAYS STAY PER DISCHARGE (HIGH OR LOW) 
AVERAGE LEAVE DAYS PER DISCHARGE (HIGH) 



I NAPPROPRIATE USE OF MEDICAL CART : 

Instances of inappropriate medical care 
utilization by specific recipients confined 
to I.TCF 



SUMMARY PROFILE REPORT: RECIPIENT 

NUMBER OF MEDICAL VISITS (HIGH OR LOW) 

NUMBER OF INJECTIONS (HIGH) 

NUMBER OF SURGICAL PROCEDURES (HIGH) 

NUMBER OF LABORATORY PROCEDURES (HIGH) 

NUMBER OF RADIOLOGY PROCEDURES (HIGH) 

NUMBER OF DAYS IN HOSPITAL (HIGH) 

NUMBER OF OUTPATIENT VISITS (HIGH) 

NUMBER OF DRUG PRESCRIPTIONS (HIGH) 

NUMBER OF NARCOTIC DRUG PRESCRIPTIONS (HIGH) 

NUMBER OF DIFFERENT DRUGS (HIGH) 



-204- 



3.2.6 



INDICATORS OF EXCEPTIONAL UTILIZATION 



DENTAL SERVICES 



SPECIFICALLY INDICATED BY REPORTS 



AREA OF EXCEPTIONAL UTILIZATION 



INDICATORS OF EXCEPTIONAL UTILIZATION 



1, . EXCESSIVE "PMERGEN'CY" SERVICES : 

Often done to circumvent prior authorization. 
Can be initiated by either dentist or recipient. 
But dentist confirms the "emergency" and invoices 
accordingly. 



SUMMARY PROFILE REPORT 
PERCENT PROCEDURES PRIOR AUTHORIZED (LOW) 



2. UNUSUAL PATTERN OF PRACTICE : 

Dental care should include a large component of 
care for prevention and not be largely concerned 
with expensive restorative work. 



SUMMARY PROFILE REPORT 

PERCENT RESTORATIVE PROCEDURES (HIGH) 
PERCENT PREVENTIVE PROCEDURES (LOW) 
AVERAGE NUMBER OF PROCEDURES PER RECIPIENT 
(HIGH) 



3. EXCESSIVE PROSTHODONTIC PROCEDURES: 



SUMMARY PROFILE REPORT 

AVERAGE NUMBER OF PROSTHODONTIC PROCEDURES 

PER RECIPIENT (HIGH) 
PERCENT PROSTHODONTIC PROCEDURES (HIGH) 



-205- 



INDICATORS OF EXCEPTIONAL UTILIZATION 



PRESCRIBED DRUGS 


SPECIFICALLY INDICATED BY REPORTS 


AREA OF EXCEPTIONAL UTILIZATION 


INDICATORS OF EXCEPTIONAL UTILIZATION 


1. UNUSUAL DISPENSING OF COMPOUNDED DRUGS: 


SUMMARY PROFILE REPORT 




PERCENT COMPOUNDED PRESCRIPTIONS (HIGH) 


• 2. UNUSUAL DISPENSING PATTERNS TO NURSING HOMES : 


SUMMARY PROFILE REPORT 




AVERAGE NUMBER OF PRESCRIPTIONS TO NURSING HOME 

RECIPIENTS (HIGH) 
AVERAGE PAYMENT PER PRESCRIPTION TO NURSING HOME 

RECIPIENTS (LOW) 


3. UNUSUAL DISPENSING OF ADDICTIVE DRUGS: 


SUMMARY PROFILE REPORT 




PERCENT RECIPIENTS WITH ADDICTIVE PRESCRIPTIONS 
(HIGH) 

AVERAGE NUMBER OF ADDICTIVE PRESCRIPTIONS PER 
RECIPIENT (HIGH) 


4. UNUSUAL DISPENSING OF OVER THE COUNTER MEDICAL 


SUMMARY PROFILE REPORT 


SUPPLIES: 


PERCENT OVER THE COUNTER SUPPLIES (HIGH) 


GENERALLY INDICATED BY REPORTS 


ARFA OF FXCEPTIOf!AL UTILIZATION 


INDICATORS OF EXCEPTIONAL UTILIZATION 


1. SPLIT PRESCRIPTION'S : 


SUMMARY PROFILE REPORT 


Excessive dispensing of sr.?ll quantity prescriptions 
J in order to accrue higher dispensing fees. 


PERCENT REFILL PRESCRIPTIONS (HIGH) 

AVERAGE PAYMENT PER PRESCRIPTION (LOW) 

AVERAGE NUMBER OF PRESCRIPTIONS PER RECIPIENT (HIGH) 

PERCENT PAYMENTS FOR PROFESSIONAL FEE (HIGH) 

- 



-206- 



UTILIZATION REVIEW PROCEDURES 



-207- 



4. UTILIZATION REVIEW PROCEDURES 



4.1.1 Analysis of Reports 

The following discussion concerns itself with suggested 
procedures for the analysis of Summary Profile, Treatment 
Analysis, and Claim Detail Reports, both individually 
and as they relate to one another. These suggested pro- 
cedures of analysis are intended to complete the process 
of discovering specific cases of probable exceptional 
utilization, a process which is initiated by the auto- 
mated exception processing techniques applied in the pro- 
duction of Summary Profiles and Treatment Analysis Reports. 
In addition to the discussion of procedures in analytical 
terms, several specific examples have been included to 
illustrate the application of these procedures. 

4.1.1.1 Procedure of Analysis 

In general terms, the procedure by which the 
MMIS S/UR Subsystem goes about isolating specific 
cases of probable exceptional utilization in- 
volves a process of elimination. Initially, all 
Medicaid providers and recipients are considered 
as potential exceptional utilizers and then are 
eliminated from consideration one by one as they 
pass certain tests. In terms on volume, the 
vast majority of potential exceptional utilizers 
are eliminated from consideration by use of the 
automated exception processing techniques dis- 
cussed in Chapter 2. When properly utilized, 
this automated exception processing will elimi- 
nate from consideration all but a relatively 
small number of providers and recipients which 
may reasonably be considered by the S/UR staff 
of a given State agency. The individual provi- 
ders and recipients presented by the S/UR Sub- 
system for manual review and analysis are those 



-208- 



most likely to be guilty of exceptional utili- 
zation on their statistical profiles. 

Regardless of the sophistication and 
ingenuity employed in the development and auto- 
mated analysis of statistical profiles, the 
capability of imbuing a computer with adequate 
medical knowledge and judgement does not pres- 
ently exist in any ptoven form. It is there- 
fore essential that individual participant 
profiles produced by -the computer system be 
analyzed by medically trained personnel before 
those participants are investigated as exceptional 
utilizers . 

Summary Profile Reports will normally be 
considered first in the process of analyzing 
individual cases of probable exceptional utili- 
zation. Within an individual Summay Profile Report 
each statistical indicator on the basis of which 
an exception was noted should be considered from 
the point of view of justifying its abnormality. 
Even though the statistical profile of an indi- 
vidual participant may deviate significantly 
from the normal profile of that participant's 
peer group, there may be valid factors of medical 
judgement which will explain and justify the 
deviation. Information to support such a justi- 
fication should first be sought within the con- 
text of the Summary Profile Report under consid- 
eration. 

Report Content Definitions contained in 
Chapter 2 for Summary Profile Reports have been 
established only for those statistical indicators 
which are correlated to specific areas of exception- 
al utilization. These indicators have been 



-209- 



entitled essential report items. It is antici- 
pated that a number of additional statistical 
indicators will be added to each Summary Pro- 
file Report for each State implementation. 
These additional statistical indicators, many of 
which have been defined in Volume III of the 
MMIS General System Design, are intended to pro- 
vide additional profile information on each 
Medicaid participant and supplement the essential 
report items. While it is not anticipated that 
these additional statistical indicators, or pro- 
file report items, will be subjected to exception 
processing, they will provide a valuable input of 
information to the process of evaluating abnor- 
malities in participant profiles detected by com- 
puter processing. 

If sufficient information is present on an 
individual Summary Profile Report to satisfy the 
medically trained reviewer that all computer 
detected, statistical abnormalities are justifi- 
able and do not merit an investigation for excep- 
tional utilization, then that report should be 
immediately eliminated from consideration. If the 
reviewer can not justify the indicated abnormal- 
ities on the basis of information contained in 
the Summary Profile Report then it will be nec- 
essary to seek information from Treatment Anal- 
ysis and/or Claim Detail Reports requested 
for the participant under consideration. 

Treatment Analysis Reports are available to 
assist in the discovery of exceptional utilization 
of the Medicaid Program on the part of physicians 
and inpatient hospitals. As described in Chapter 
2, these reports may be produced on an exception 



-210- 



basis and/or an individual selection basis. 
When produced on an exception basis. Treatment 
Analysis Reports will serve to complement the 
exceptional utilization discovery function of 
Summary Profile Reports by accomplishing a sta- 
tistical analysis of physician and inpatient 
hospital services at the level of individual dia- 
gnosis - treatment interrelationships. Due to the 
detailed nature of these reports it is unlikely 
that an individual abnormality in a statistical 
profile can be explained on the basis of other 
information contained in the report. Therefore, 
it will normally be necessary to seek information 
from a Claim Detail Report in order to adequately 
review an exception noted in a Treatment Analysis 
Report . 

Treatment Analysis Reports may also be 
selected for individual physicians and inpatient 
hospitals. This selection would be motivated by 
a need for additional information to justify an 
abnormality noted in a Summary Profile Report. 

Quite often a statistical abnormality 
causing a physician or inpatient hospital to be 
excepted on a Summary Profile Report may be ex- 
plainable by an unusual combination of medical 
problems treated as compared to the peer group 
norm. This situation could be particularly 
applicable to providers who carry a relatively 
low Medicaid patient load. Since Treatment 
Analysis Reports provide treatment profiles for 
each individual diagnosis code reported by a 
given provider, they may well provide all infor- 
mation required to justify a Summary Profile 
Report'-exception based on medical necessity. 

-211- 



If the reviewer can not justify the indi- 
cated abnormalities from the Summary Profile 
Report on the basis of information contained in 
the Treatment Analysis Report then it will be 
necessary to seek information from Claim Detail 
Reports requested for the provider under consid- 
eration. 

Claim Detail Reports provide the most 
detailed information regarding Medicaid utiliza- 
tion which can be made available by the S/UR 
Subsystem. These reports will present all essen- 
tial information available from all Medicaid 
claims paid within a time period established by 
the user. Claim Detail Reports are requested for 
specific providers or recipients in an attempt to 
justify abnormalities detected by Summary Profile 
and/or Treatment Analysis Reports. Through the 
use of these reports, the reviewer will be able 
to consider both the nature and the timing of 
each specific service rendered or received to the 
extent that it is desc£4ke£ on a claim form. 

If a review at the individual claim level 
of detail finds no satisfactory justification for 
reported abnormalities, then it will be necessary 
to initiate an investigation into the activities 
of the specific provider or recipient suspected 
of exceptional utilization. The reviewer should 
initiate this investigation by documenting the 
suspected area of exceptional utilization with 
all relevant information compiled from the 
various S/UR reports, and turning the matter over 
to the appropriate medical professional for 
review and action. 



-212- 



4.1.1.2 Examples of Procedures 



The following examples of procedures of 
analysis are organized according to the report 
which initiates the analysis. Each example 
contains the following information, organized 
in outline form: the indicator which caused 
the provider or recipient to be excepted, the 
probable area of exceptional utilization in- 
dicated, possible justification for the exception 
and a listing of additional information available 
which may be of value to the reviewer in determin 
ing the need to investigate the excepted pro- 
vider or recipient for exceptional utilization. 



-213- 



SUMMARY PROFILE REPORT: RECIPIENT 



INDICATORS: 



High number of different physicians 
High percent initial visits 



PROBABLE AREA OF EXCEPTIONAL UTILIZATION: 



Doctor Shopping 



POSSIBLE JUSTIFICATION: 



Multiple medical problems requiring 



services of specialists or medical condition requir- 
ing consultants. 



Number of different diagnoses 

Number of surgical procedures 

Number of diagnostic laboratory procedures 

Number of diagnostic radiology procedures 

Number of drug prescriptions 

Number of different drugs 

Number of days in hospital 

Number of days in long term care facilities 



Claim Detail Report: 

Specific diagnosis codes, procedure codes, and dates 
of service. 



ADDITIONAL INFORMATION AVAILABLE: 



Summary Profile Report: 



-214- 



SUMMARY PROFILE REPORT: RECIPIENT 



INDICATOR : High number of medical visits 

PROBABLE AREA OF EXCEPTIONAL UTILIZATION : Excessive medical visits 

POSSIBLE JUSTIFICATION : Severe or multiple medical problems 
requiring extensive physician care. 

ADDITIONAL INFORMATION AVAILABLE : 

Summary Profile Report: 

Number of different diagnoses 

Number of surgical procedures 

Number of days in hospital 

Number of days in long term care facilities 

Claim Detail Report: 

Specific diagnosis codes, procedure codes, and dates 
of service. 



-215- 



SUMMARY PROFILE REPORT: RECIPIENT 



INDICATOR : High number of transporation services 

PROBABLE AREA OF EXCEPTIONAL UTILIZATION : Excessive transportation 
utilization 

POSSIBLE JUSTIFICATION : Recipient has no personal transportation 
available and requires extensive ambulatory care. 

ADDITIONAL INFORMATION AVAILABLE : 

Summary Profile Report: 

Number of physician office visits 

Number of drug Rx 

Number of dental services 

Number of outpatient hospital visits 

Number of inpatient hospital admissions 

Claim Detail Report: 

Specific dates of service and categories of service 
received. 



-216- 



SUMMARY PROFILE REPORT: PHYSICIAN SERVICES 



INDICATORS : High ratio of office injections to office visits 
High ratio of injections to recipients 

PROBABLE AREA OF EXCEPTIONAL UTILIZATION : Excessive injections per 
recipient 

POSSIBLE JUSTIFICATION : A high percentage of ambulatory patients 

have diseases requiring frequent medication which must 
be administered by injection under a physician's 
supervision. 



ADDITIONAL INFORMATION AVAILABLE: 



Summary Profile Report: 

Ratio of drug prescriptions to visits 
Ratio of drug prescriptions to recipients 
Ratio of hospital discharges to all recipients 
Ratio of recipients in long term care facilities to 

all recipients 
Percent of invoice amount paid 

Treatment Analysis Report: 

Relative number of recipients with specific diagnosis 
codes which are known to require injectable medication 

Claim Detail Report: 

Specific diagnosis codes, procedure codes and dates of 
service . 



-217- 



SUMMARY PROFILE REPORT: INPATIENT HOSPITAL SERVICES 



INDICATORS : High percent payment for ancillary services 
High average ancillary payment per discharge 

PROBABLE AREA OF EXCEPTIONAL UTILIZATION : - Excessive ancillary 
service charge 

POSSIBLE JUSTIFICATION : A high percentage of hospital stays are 
for short durations, and/or involve surgery, and/or 
require intensive care, extensive monitoring, chemo- 
therapy, radiation therapy, etc. 

ADDITIONAL INFORMATION AVAILABLE : 

Summary Profile Report: 

Average days stay per discharge 
Percent discharges 1 day 
Percent discharges 2 days 
Percent discharges with surgery 

Average ancillary payment per surgical discharge 
Average ancillary payment per non-surgical discharge 
Percent payments for ancillaries-surgical discharges 
Percent payments for ancillaries-non-surgical discharge 

Treatment Analysis Report: 

Relative number of discharges with specific diagnosis 
codes which are known to require a high level of 
ancillary services. 

Claim Detail Report: 

Specific diagnosis codes, days of stay, and surgical 
procedure codes. 



-218- 



SUMMARY PROFILE REPORT: OUTPATIENT HOSPITAL SERVICES 

INDICATORS : High ratio of drug prescriptions to visits 

High ratio of drug prescriptions to recipients served 

PROBABLE AREA OF EXCEPTIONAL UTILIZATION : Unusual prescribing 
practices 

POSSIBLE JUSTIFICATION : A high percentage of patients have medical 
conditions which require treatment by self administered 
medication. 

ADDITIONAL INFORMATION AVAILABLE : 

Summary Profile Report: 

Ratio of injections to visits 
Ratio of injections to recipients 
Percent of invoice amount paid 

Claim Detail Report: 

Specific diagnosis codes and procedure codes. 



-219- 



SUMMARY PROFILE REPORT: DENTAL SERVICES 
INDICATOR : Low percent services prior authorized 

PROBABLE AREA OF EXCEPTIONAL UTILIZATION : Excessive emergency services 

POSSIBLE JUSTIFICATION : Dental work for Medicaid recipients is 
not routinely provided; majority of services are 
provided on an emergency basis only. 

ADDITIONAL INFORMATION AVAILABLE : 

Summary Profile Report: 

Number of recipients served 

Percent of services for diagnostic procedures 
Percent of services for preventive procedures 
Percent of services for restorative procedures 
Percent of services for endodontic procedures 
Percent of services for periodontic procedures 
Percent of services for prosthodontic procedures 
Percent of services for oral surgery 
Percent of services for orthodontic procedures 

Claim Detail Report: 

Specific procedure codes and dates of service. 



-220- 



SUMMARY PROFILE REPORT; PRESCRIBED DRUGS 

INDICATOR : High percent compounded prescriptions 

PROBABLE AREA OF EXCEPTIONAL UTILIZATION : Unusual dispensing of 
compounded drugs 

POSSIBLE JUSTIFICATION : Pharmacy is located in close proximity 
to, or is associated with a number of dermatologists 
or other practitioners who typically prescribe com- 
pounded drugs and provides services to a relatively 
low number of Medicaid recipients. 

ADDITIONAL INFORMATION AVAILABLE : 
Summary Profile Report: 

Number of recipients served 

Percent of prescriptions for drugs in each major 
therapeutic class 



Claim Detail Report: 

Specific drug codes and diagnosis codes. 



-221- 



4.1.2 Investigatory end Remedial Actions - Definitions end 
Requisites 

While the distinction between investigatory and 
remedial actions is not always solid, the two terms ere 
used here to describe phases of the S/QR process. In- 
vestigatory actions ere those used in obteining e.ddi- 
tional date, from outside the MMIS in order to render 
judgment on the quantitative and qualitative adequacy of 
medical services rendered - especially on the medical 
necessity or appropriateness of instances of exceptional 
utilization. Remedial actions ere those taken a.fter the 
investigatory activities have been completed to correct 
documented instances of misuse of Medicaid. 

There are several requisites to be met if suffi- 
cient information beyond that available in S/UR reports 
is to be collected to support judgments about the services 
rendered and to provide a besis for ection egeinst either 
providers or recipients who heve misused Mediceid. 

4,1.2.1 Sufficient Documentation 

All pertinent dete from the Summery Pro- 
file, Treatment Ane lysis, Claims Detail, or Re- 
quested Special Reports must be reviewed before 
an apparently exceptional situation is investi- 
. gated. The review will aid in determining 
whether the norms used for the reports are ree- 



-222- 



sonable as well es eliminate from investigation 
situations which are expleneble when date from 
several sources is considered together. In 
addition to such data, the conduct of investi- 
gatory activities requires the originals of claims 
submitted or acceptable copies and clear communi- 
cation to assure that purpose, scope, timing, and 
responsibilities of all parites are understood. 

4.1.2*2 Establishment of Priorities 

Investigatory activities should focus first 
on those expensive, high volume services most 
amenable to post payment utilization review. 
While the focus will vary according to services 
included in the Plan, in many States, the choice 
will include inpatient hospital care, physician 
end outpatient hospital services, end drugs. In 
deeling with providers or recipients who were 
exception to norms, it is advisable to start with 
those for whom several exceptions were noted. 
Since providers exercise control over the pro- 
vision of most services and since they often 
serve many recipients, effective S/UR will give 
first emphasis to providers that exceed norms 
rather than recipients who do so. 

While situations which fall outside the 
normal range will be given priority, occasional 

-223- 



or routine sampling of situations within the 
normal range should also "be done. Abuse of 
Medicaid is not confined to medical events 
which exceed norms, "but can occur with care well 
within established norms. 

4.1.2.3 Legal Advice 

Legal counsel should he sought to provide 
assurance that the Medicaid agency meets its 
administrative responsibilities f orthrightly, 
but without jeopardizing the legal rights of 
providers or recipients and with concern for 
professional ethics. 

4ii«2«4 Safeguards Against Capricious Action 

Decisions to proceed with field investi- 
gations may be made by the professional person 
in charge of utilization review oftlfckeppelrMmant 
category of service after thorough review of all 
data available within the system. Before pro- 
ceeding with the investigation he may wish to 
obtain a broader perspective by having the 
available information reviewed by consultant 
specialists or an ad hoc advisory group sometimes 
drawn from the grievance committee of the perti- 
nent professional organization or a subcommittee 
of the Medicaid advisory committee. In addition 
the procedures for instigating and conducting 

-224- 



Investigations should "be a matter of policy. 
In some jurisdictions , Agency administrators or 
policy making boards , on the recommendation of 
utilization review staff, determine which sit- 
uations require investigation and which remedial 
actions are suitable. The exact procedures and 
placement of responsibility are not so important 
as the need for sufficient structure to diffuse 
responsibility and to establish readily under- 
standable guidelines. 

4.1*2.5 Co-operative Attitude of the Professional Organi- 
zations and Societies of the Providers 

Without a co-operative attitude the State 
Agency will be handicapped in conducting its 
utilization efforts, at least, for the following 
reasons . 

1) It will have lost a powerful source 

of manpower to make difficult decisions con- 
cerning the medical necessity, quantitative 
and qualitative adequacy, and economy and 
efficiency of services paid by Medicaid. 

2) It will have lost a source of sanction, 
what a State Agency including its profes- 
sional employees thinks of the practice of 
a provider may be relatively unimportant 

to him. However, in most instances he does 

-225- 



care about the attitude of his colleagues. 

3) An important vehicle for communication 
will he lost. Instead of setting up a 
series of communications to providers, or 
a supplement to existing newsletters, in- 
formational materials on utilization re- 
view policies, procedures, casestudies, 
results etc. can he transmitted through pro- 
fessional organization media with a better 
chance of being read. 

4.1.2.6 Adequate Staff and Resources 

Much has been discussed about the need for 
flexibility in designing S/UR systems and of the 
necessity of generating no more paper than can 
be handled by staff. But we need to guard 
against the implementation of s sophisticated, 
full blown computerized S/UR system which will be 
used at only a fraction of capacity if existing 
levels of staffing are maintained. Considering 
the number of claims and the money expended, the 
volume of exceptional claims in even a small or 
medium size Medicaid program is substantial. If 
staff is so limited that criteria must be set too 
loosely the investment in computerization is 
largely wasted. Xnite&d of tailoring the exception 
reports .too t2he size off* - ifcfee* s&aff , ftfee: M«ecof^ the 
staff should be tailored to the number of ex- 
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ceptiens irhiek result- nhm reaaan^tLe* e*ceg£ion 
criteria «re used*. 

The flexibility of the system is "best 
used to change the focus of S/UR activities 
among categories of service and aid categories,, 
to modify exception criteria and report items 
as required, and to reduce the volume of reports 
during temporary staff shortages. But the 
flexibility of the system should not be an ex- 
cuse for inadequate utilization review nor should 
the expected deterrent of the mere existence of 
a utilization review effort be relied on too 
heavily to control errant providers and recipients 

The S/UR reports not only identify exception 
al situations over time, they also provide a 
measure of the success of S/QR activities. 

4.1.2.7 Provider Agreements 

When agreements with individual providers 
are used, they provide a good vehicle for estab- 
lishing the respective roles and responsibilities 
of the State Agency and the provider when investi- 
gatory activities and corrective actions are 
necessary. Gare should be taken to present these 
roles and responsibilities in a positive way which 
assumes that the bulk of medical care provided 



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is acceptable, "but which indicates that ex- 
ceptional situations, especially exceptional 
patterns of practice often will be investigated. 

4,1.3 Investigatory Activities 

In many instances the data available from S/UR re- 
ports will be insufficient for utilization review staff 
to determine whether situations identified as exception- 
al were, in fact, acceptable medical care. In other 
instances, complaints emanating from outside the manage- 
ment information system may require investigation. In 
either event' additional data must be obtained. The addi- 
tional data may be collected either informally or for- 
mally. Generally, formal measures should not be used 
until informal ones have been exhausted. By informal 
methods are meant telephone conversations, letters, and 
visits with providers to establish a working relationship, 
assess understanding of the program, elicit cooperation 
and to obtain general information about the provider's 
practice or clientele which may serve to distinguish them 
from others in the same grouping* This may be sufficient 
to determine that the provider has been inappropriately 
grouped, or that appropriately grouped, the circumstances 
are sufficiently different to account for medical care 
outside the norms (e.g. a ghetto practice, or lack of 
appropriate alternative care facilities). 



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4.1.3.1 Provider Visits and Audits 

Frequently on-site visits to providers 
or audits may be needed to compare medical and 
financial records against claims submitted. 
These on-site reviews may be used: 1) to make 
a judgment on exceptional situations identified 
by S/UR or, 2) to occasionally or routinely in- 
vestigate situations which are within the normal 
range. While priority may be given to the ex- 
ceptional situations, attention should also be 
given misuse of the program which can occur with 
medical care well within the established norms. 

4.1.3.2 Recipient Contacts 

Recipients as well as providers may need 
to be contacted. Sometimes this contact may 
be accomplished by letter or telephone, but more 
often it will require involvement of a person 
especially employed for this work (sometimes 
called a Medicaid Recipient Counselor) or a case- 
worker. In either situation, the contact with 
the recipient should occur as quickly as possible 
after the receipt of medical care since the re- 
call of recipients (and people, generally) regarding 
medical care is jsatorioiffsly poor. 

The interview should be aided by docu- 
mentation - copies of the bills presented as well 

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as a detailed listing of care provided. The 
latter may be in the form of an "Explanation 
of Services Rendered" a Medicaid counterpart 
of the Medicare "Explanation of Benefits". 

4. 1 . 3. 3 Informal Hearings 

Another means of determining whether the 
exceptional situations reported "by S/QR can "be 
justified is the informal hearing. The pro- 
vider is requested to appear, with counsel, if 
he wishes. He is presented with information on 
the norms for his grouping as well as the ex- 
ceptions which have been noted and the detail of 
the claims which have been submitted. 

4.1.3.4 Medicare Data 

A source of referrals and a secondary 
source of information, not to be overlooked, in 
planning and conducting investigatory activity 
is the Medicare program - especially its Program 
Integrity staff and reports. In this regard the 
responsibilities of the Medicare and Medicaid 
programs are reciprocal with each having an obli- 
gation to furnish pertinent data to the other. 
In some instances joint field investigations by 
a staff comprised if both Medicare and Medicaid 
employees may be feasible and desired. 



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4.1.4 Remedial Actions 

S/UR. Remedial Actions essentially are of two forms: 
1) Education and Communication, and 2) Corrective Actions. 
The former may be concerned with individual recipients 
or providers or with groups of either. While the edu- 
cation and communication function is largely a State Medi- 
caid Agency responsibility,, the agency may use help from 
other State agencies, fiscal agents or organizations of 
providers or recipients. For instance there may be 
informal discussion of problems with providers, with in- 
dividual providers, or groups of providers when the need 
is general, or with organizations of providers or reci- 
pients. Personnel likely to be involved are Medical 
Assistance Unit Staff including members of Medical Assist- 
ance Advisory Committees or subcommittees, and the agency 
Director. Likewise discussion of recipient problems may 
invalve individual recipients, or groups of recipients 
when the need is geneEal, or with organizations which re- 
present recipients. Agency staff likely to be involved 
include caseworkers, Medicaid recipient counselors, other 
appropriate medical assistance unit staff, and the agency 
Director. 

Purpose of the education and communication is: 1) 
to present and clarify Medicaid objectives and S/UR con- 
cepts, procedures, and accomplishments, 2) to foster 



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cooperative attitudes and obtain professional sanction, 
and 3) to solicit professional knowledge and manpower. 

The range of corrective actions which may he nec- 
essary when errant providers have not responded to edu- 
cational and communication functions is great. The 
following list is presented in order of severity. As 
with investigatory activities, the least severe cor- 
rective action which accomplishes its purpose is the 
desirable one. While in many instances only one form of 
corrective action will "be needed, others may require 
multiple corrective actions. 

4,1,4,1 List of Corrective Actions 
Corrective Actions 
Providers 

Require prior authorization for all ser- 
vices provided by a specific provider. 
Recovery of past payments: 
Voluntarily 

Credit against outstanding otr gufeure 
obligations . 
Recovery of payments by legal action 
Temporary or permanent suspension from 

participation in program. 
Referral to grievance committee of the 

pertinent Professional Association 
Referral to proper legal authorities for 
alleged fraud. 
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Referral to State licensing Board for 
appropriate action. 
Recipients 

Counselling 

Require prior authorization for receipt 
of non-emergent medical services. 

Restrict receipt of services to specific 
providers (lock-in). 

Recovery of improper expenditures 
voluntarily. 



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4.2 SYSTEM CONTROL PROCEDURES 



4.2.1 Introduction 

Operation of the MMIS S/UR Subsystem will involve two 
organizational units within a State Medicaid establishment: 
one responsible for the conduct of S/UR activities and the 
other responsible for providing data processing services. 
It is intended that control over all variable features of 
the S/UR Subsystem be exercised by the S/UR unit through 
the agency of system control parameters. These parameters 
will be transmitted to the data processing unit at sched- 
uled time intervals for entry into the computer system. 
Under control of these parameters, the computer system will 
produce the various S/UR reports which will then be for- 
warded by the data processing unit to the S/UR unit. 

This interchange of system control parameters and 
reports constitutes the primary interface between the S/UR 
and data processing units. A step by step discussion of 
the operating procedures which define this interface in 
detail may be found in Volume III, Chapter C of the MMIS 
General Design Documentation and, therefore, is not 
repeated here. Rather, it is the intent of the following 
discussion to outline the procedures by which the two 
primary types of system control parameters are intended to 
be utilized by the S/UR unit. 

4.2.2 Class Group Control 

A primary concept upon which S/UR Subsystem exception 
reporting techniques are based requires that providers and 
recipients be classified into peer groups. Providers are 
intended to be classified within each category of service 
according to the manner in which they deliver health care 
services and, where applicable, the specialized nature of 



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those services. Recipients are intended to be classified 
according to their probable need for medical care. While 
there is not sufficient information available to the S/UR 
Subsystem to meet these intended classifications with 
absolute precision, there is information coded into the 
MMIS data element structure which will permit generally- 
accurate groupings of providers and recipients for pur- 
poses of exception reporting. 

Specific data elements on the basis of which it is 
recommended that providers be classified are: provider 
type code, provider location code, and provider specialty 
code. Specific data elements which are recommended for 
purposes of recipient classification are: recipient age, 
recipient location code, recipient aid category, and 
recipient long term care confinement status. 

In order to establish a class group the user will 
establish a series of values for each of the data elements 
listed above and enter these values into a class group 
control parameter set. Also entered into the parameter 
set will be a unique code, known as a class group code, 
which will identify the class group to the computer system. 
For recipients each class group code must be unique among 
all such codes assigned. For providers each class group 
code must be unique only within a category of service. 

When the computer system is activated, each individual 
participant will be classified into a class group by com- 
paring the values of data elements recorded for that parti- 
cipant against the series of values established for each 
corresponding data element entered into each class group 
control parameter set until a match is found. A recipient 
may be classified into only one class group, while a pro- 
vider may be classified into only one class group for each 
category of service he is authorized to provide. 



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The actual number and nature of class groups estab- 
lished for recipients and for each provider category of 
service will depend heavily upon the characteristics of 
the recipient and provider populations of each State. At 
a minimum it is recommended that practitioners be classi- 
fied according to their medical specialties and recipients 
be classified according to their age and long term care 
confinement status. 

4.2.3 Exception Control 

After classification of Medicaid providers and recip- 
ients into class groups has been accomplished, it is nec- 
essary to consider the establishment of a set of specific 
exception criteria for each such class group. As discussed 
earlier under Report Descriptions, exception criteria are 
automatically established by the computer system and the 
data used in the computation is displayed to the user in 
Management Summary Reports. Although this automated 
establishment of exception criteria will proceed without 
any user intervention it is anticipated that the results 
achieved in this manner will not be completely acceptable 
in every instance. It is, therefore, recommended that the 
user review the system generated exception criteria and 
adjust them where necessary before they are used in the 
production of Summary Profile Reports and Treatment Anal- 
ysis Reports. 

There are two ways in which the user can control the 
generation of exception criteria. First, the user may 
specify the number of standard deviations which are added 
to and subtracted from the average of each report item in 
a exception criteria set. If the number of standard • 
deviations to be so used is not specified for any given 
report item then a predetermined number will be assumed. 
It is recommended that this default number of standard 



-236- 



deviations be established at two. The number of standard 
deviations applied to the generation criteria for a given 
report item can be translated into the minimum percent of 
participants who will fall within those criteria for that 
report item by use of the following mathematical relation- 
ship : 

P + (1 - 1/N 2 ) x 100, where 

P is the minimum percent of participants who will fall 
within the range established by the exception criteria, and 
N is the number of standard deviations necessary to produce 
the percentage. The results produced by this formula are 
significant only when the number of standard deviations is 
greater than one. By use of this relationship it can be 
determined that use of two standard deviations will produce 
exception criteria within which at least 751 of partici- 
pants will fall; therefore, a maximum of 25% of partici- 
pants would be reported as exceptions. 

The second method by which the user can control the 
generation of exception criteria requires the entry of 
actual exception criteria values into the computer system. 
Thus, the user may exercise absolute control over the 
exception reporting process by overriding automatically 
generated exception criteria with specific criteriaaof his 
own choosing. 



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5 . APPENDIX 



-238- 



5.1 GLOSSARY OF TERMS 



Term 



Adjudicate 



Adjustment 



Aid Category- 



Benefits 



Category of Service 



Claim 



Claim Transaction 



Definition 

To determine whether a claim (credit, 
or adjustment) is to be paid or dis- 
allowed . 

A transaction which has the effect of 
changing the payment amount of and/or 
the units of service of a previously 
submitted or paid claim. 

A designation within the State Social 
Services Department under which a 
person may be eligible for public 
assistance and/or medical assistance. 

Services available under the Medicaid 
Program. 

A classification of medical services 
authorized under Medicaid (e.g., 
physician, inpatient hospital, ECF, 
ICF, etc.) 

A bill rendered by a provider to the 
Single State Agency for a procedure, 
a set of procedures, or a service 
rendered to a recipient for a given 
diagnosis or set of related diagnoses. 
(More than one claim may appear on 
certain ledger-type input forms. In 
this case, entries on the claim form 
represent separate claims, rather 
than line items.) 

Any one of the records processed 
through the Claims Processing Subsys- 
tem. Examples are: 

1. Claims 



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Term 



Definition 



Class Interval 



Control Break 



Control Heading 



Credit 



Crossover Claims 



Data Element 



Drug Formulary 



Eligibility File 



Exceptional Utilization 



2. Credits 

3. Adjustments 

4. Queries 

5. Approved Prior Authorizations 

The difference between the upper and lower 
limits of a value range used in a frequency 
distribution. 

A break in the printing of detail data by 
the Report Writer based on some control 
field, eg., Provider Number. Control 
breaks are used for the purpose of printing 
totals and/or other statistics. 

Descriptive, literal data inserted above 
totals printed by the Report Writer at 
each control break. 

A claim transaction which has the effect 
of reversing a previously processed claim 
transaction . 

Claims for which both Titles XVIII and 
XIX are liable for services rendered to 
a recipient entitled to benefits under 
both programs. 

A specific unit of information having a 
unique meaning. 

A listing of drugs covered by the State 
Medicaid Plan which includes the drug 
code, description, strength, and manu- 
facturer . 

A file containing individual records for 
all persons who are eligible or have been 
eligible for Medicaid. 

Any usuage of the Medicaid Program by any 
of its providers and/or recipients not 



Term 



Definition 



Field Audit 



Free-Format 



Institution 



Line Item 



Medical Assistance 
Unit 

Module 



Order- Independent 



Participant 



in conformance with both State and Fed- 
eral regulations and laws (includes 
fraud, abuse, and defects in level and 
quality of care) . 

An activity performed by the State 
Medicaid Agency whereby a provider's 
facilities, procedures, records and 
books are audited for conformance to 
Medicaid standards. A field audit may 
be conducted on a regular routine basis, 
or on a special basis to investigate 
suspected exceptional utilization. 

With respect to Report Writer specifications 
free-format means that no particular struc- 
ture is required of those specifications. 

An organization which provides medical 
services for persons confined within its 
structure (e,g,, a hospital, nursing 
home , etc . ) . 

A single procedure rendered to a recip- 
ient. A claim is made up of one or more 
line items for the same recipient. 

See the Handbook of Public Assistance 
Administration, Supplement D, Item 7200. 

A group of data processing and/or manual 
processes that work in conjunction with 
each other to accomplish a specific 
function . 

With respect to Report Writer specifications 
order- independent means that no particular 
sequence is required of those specifications 

One who participates in the Medicaid pro- 
gram as a provider or a recipient. 



Term 



Definition 



Peer 

Peer Review 



Practitioner 

Prior Authorization 

Provider 

Profile 



Reasonable Charge 

Recipient 
Report Item 



A person or committee in the same pro- 
fession as the provider whose claim is 
being reviewed. 

An activity performed by a group or 
groups of practitioners or other pro- 
viders, by which the practices of their 
peers are reviewed for conformance to 
generally accepted standards. 

An individual provider - one who prac- 
tices a health or medical service pro- 
fession. 

The approval which must be given by the 
Medical Assistance Unit for specified 
services for a specified recipient to a 
specified provider. 

A personv organization, or institution 
certified to provide health or medical 
care services authorized under a State 
Medicaid Program. 

An outline of the most outstanding 
characteristics of a vendor practice 
in rendering health care services and 
recipient usage in receiving health 
care services. 

Charge for health care service rendered 
that is consistent with the efficiency, 
economy, and quality of the care pro- 
vided. 

One who received Medicaid services. 

Any unit of information or data appearing 
on an output report. 



Term 



Definition 



Specialty The specialized area of practice of a 

physician. 

Specialty Certification or approval by a Profes- 

Certif ication sional Academy, Association, or Society 

which designates that this provider has 
demonstrated a given level of training 
or competence and is a "fellow" or 
specialist . 

Specifications Within the context of the Report Writer 

Module, specifications are coded instruc- 
tions supplied by the user by means of 
which special reports are requested and 
defined . 

S/UR Unit The section of the Medical Assistance 

Unit responsible for surveillance and 
utilization review activities in the 
State or county. 

Third Party A condition whereby a person or an 

Liability organization other than the recipient 

or the Single State Agency is responsible 
for all or some portion of the costs 
for health or medical services incurred 
by a Medicaid recipient (e.g., a health 
insurance company, a casualty insurance 
company or another person in the case 
of an accident, etc.). 

Transaction A number stamped on each claim trans- 

Control Number action document to uniquely identify 

the transaction throughout all process- 
ing. 



Term 



Definition 



Trend 

Utilization Review 
Value Range 



A measure of the rate at which the 
magnitude of data is changing. 

The process of monitoring and control- 
ling, to the extent possible, the 
quantity and quality of health care 
services delivered under the Medicaid 
Program. 

A range of numeric values defined by an 
upper limit and a lower limit. With 
respect to a frequency distribution, the 
difference between the limits of a value 
range is called a class interval. 



GPO 938-864 



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