r
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,
-2-
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.
-14-
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)
-28-
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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
REPORT FORMAT EXAMPLE
(On following page)
-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
REPORT FORMAT EXAMPLE
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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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■96-
2.5.4.2 MANAGEMENT SUMMARY REPORT: PHYSICIAN SERVICES CLASS PROFILES
REPORT FORMAT EXAMPLE
(On following page)
-97-
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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)
-106-
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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)
-141-
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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)
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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-
-226-
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
-227-
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).
-228-
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
-229-
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.
-230-
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
-231-
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.
-232-
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.
-233<
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
-234-
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.
-235-
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.
-237-
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
-239-
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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