URSA-CORE-920: Professional Claims with Suspected Duplicate

Measure Description

Among professional claim service line items, the percentage for which another record exists with identical patient, service start date, line number, HCPCS code plus the first HCPCS modifier code, and service provider. A positive value suggests the claims data have not been properly reconciled to final action, or some other failure to resolve duplicates.

Metadata

• Measure Type: Rate Measure
• Temporal Structure: Event
• Component Class: Normal-Form
• Denominator Case Field: Claim Service Line Item ID
• Target Direction: Down

Denominator Description

Professional claim service line items.

Numerator Description

Denominator observations with at least one other professional claim service line item with the same patient, service start date, service line number, HCPCS code plus the first HCPCS modifier, and service provider.

Published Fields

• Data Model Keys

  • Claim ID
  • Claim Service Line Item ID
  • Service Line Number
  • Patient ID
  • Service Provider ID
  • Payor ID
  • Source ID

• Date Fields

  • Service Start Date
  • Segment Start Date -- The start date of the reporting segment. (See also [URSA-CORE] Reporting Segment)
  • Segment End Date -- The end date of the reporting segment. (See also [URSA-CORE] Reporting Segment)

• Clinical Services Fields

  • HCPCS Code
  • HCPCS Modifier 1 Code

• Financial Fields

  • Claim Service Line Item Allowed Amount
  • Claim Service Line Item Plan Paid Amount

• Numerator Fields

  • Count of Suspected Duplicate Records

• Measure Fields

  • Denominator
  • Numerator