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pdfEQR PROTOCOL 6 – Calculation of Performance Measures
Attachment A: Performance Measure Calculation Tables
Table 1: Example List of Measures for Calculation
Measure
Childhood
Immunization Status
Otitis Media with
Effusion
Screening using
standardized
screening tools for
potential delays in
social and emotional
development
Well child visits in the
first 15 months of life
Well child visits in the
3rd, 4th, 5th and 6th
years of life
Measure Source
HEDIS® 2011/
CHIPRA Core
Measure
AMA PCPI
Reporting Frequency
Annual
Date Report Due
June 15
Annual
September 30
State
Quarterly
April 20, August 20,
November 20,
January 20
HEDIS® 2011/
CHIPRA Core
Measure
HEDIS® 2011/
CHIPRA Core
Measure
Annual
June 15
Annual
June 15
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EQR Protocol 6 Attachment A
Performance Measure Calculation Tables
September 2012
1
Table 2: Example Companion Performance Measurement Worksheet
Complete the worksheet for each measure listed in Table 1.
Measure
State Requirements for Measure
name/title/identifier
Measure Purpose
Data collection method
Sampling method (if
applicable)
Age
Gender
Continuous Enrollment
Index event
Denominator elements
and data sources
Numerator Elements and
data sources
Denominator
Numerator
Rate Calculation
Benchmark(s)
Other analysis
requirement
QI or PIP
Demonstration
Pay for Performance/Value-based purchasing
Public Reporting
Other (specify)
Electronic Only
Manual Only
Survey
Electronic supplemented by medical record review (hybrid)
Specifications for sample size, sampling method and replacement methods
Lower age limit
Upper age limit
Males Only
Females Only
Males and Females
No
Yes: specify
e.g., Birthday; discharge; Rx fill; Diagnosis; Procedure
A list of each data element, e.g., member ID, age, gender, enrollment and
disenrollment dates, diagnoses, procedures, and all other elements needed to
establish eligibility for the denominator For each denominator element, the
allowable data source(s)
A list of each data elements, e.g., procedure codes, diagnosis codes,
pharmacy codes, lab results, dates of service, and all other elements needed
to establish eligibility for the numerator
For each numerator element, the allowable data source(s)
Denominator Statement
Inclusions/Exclusions
Denominator Time Window
Numerator Statement
Inclusions/Exclusions
Numerator Time Window
Formula for calculation of rate
State, region, nation, other, source
A list of analyses required, such as change from prior year or comparison to
state average or best in state, including any statistical tests required
EQR Protocol 6 Attachment A
Performance Measure Calculation Tables
September 2012
2
Table 3: Data Element Master Worksheet
Place a checkmark in the cell to indicate the data element is required for the measure.
Denominator
Data
Elements
Date of birth
Sex
Enrollment
date
Disenrollment
date
Diagnosis
code
Procedure
code
Service date
Provider ID
Numerator
Data
Elements
Diagnosis
code
Procedure
code
Pharmacy
code
Lab order
Lab result
Performance
Measure 1
Performance
Measure 2
EQR Protocol 6 Attachment A
Performance Measure Calculation Tables
September 2012
Performance
Measure 3
Performance
Measure 4
Performance
Measure 5
3
Table 4: Data Source, Completion and Integration Issues
Denominator
Data Elements
Date of birth
Sex
Enrollment date
Disenrollment
date
Diagnosis code
Procedure code
Service date
Provider ID
Numerator Data
Elements
Diagnosis code
Procedure code
Pharmacy code
Lab order
Lab result
Available
Source(s)
Available
Source(s)
EQR Protocol 6 Attachment A
Performance Measure Calculation Tables
September 2012
In MCO
Repository?
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
In MCO
Repository?
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Completeness/Integration issues
Completeness/Integration issues
4
Table 5: Example File Format for Transmission of Claims Data
Field #
Data Field
Applies to
UB Phys Rx
X
X
X
X
X
X
Type/Format
Req/Opt
Comments
Char(1)
Char(1)
Required
Required
1=UB, 2=Phys, 3=Rx
P=Paid, D=Denied
Denied claims are
highly desirable for
accurate
performance
measurement
Medicaid or CHIP
identifier supplied by
the State for the
member. Native or
encrypted. If
encrypted, separate
encryption key must
be provided.
Required if source is
not sending final-only
versions of claims
Required if source is
not sending final-only
versions of claims
Required if source is
not sending final-only
versions of claims
Required if source is
not sending final-only
versions of claims
Any internal identifier
for the billing
provider. Must be
unique to one
clinician or entity.
Must exist on the
provider file. If
supplying for Rx, use
pharmacy provider
ID.
1
2
Row Type
Claim Status
3
Recipient ID
X
X
X
Varchar(50)
Required
4
Claim Number
X
X
X
Varchar(80)
Required
5
Prior Version Claim
Number
X
X
X
Varchar(80)
Required
6
Claim Received Date
X
X
X
yyyymmdd
Required
7
Claim Paid Date
X
X
X
yyyymmdd
Required
8
Billing Provider ID
X
X
X
Varchar(30)
Required
EQR Protocol 6 Attachment A
Performance Measure Calculation Tables
September 2012
5
9
Principal Diagnosis
Applies to
UB Phys Rx
X
X
10
Diagnosis 2
X
X
Varchar(5)
Required
11
Diagnosis 3
X
X
Varchar(5)
Required
Field #
Data Field
Type/Format
Req/Opt
Varchar(5)
Required
Comments
No periods, left
justified
No periods, left
justified
No periods, left
justified
END OF DOCUMENT
EQR Protocol 6 Attachment A
Performance Measure Calculation Tables
September 2012
6
| File Type | application/pdf |
| File Title | EQR protocol 6 - Calculation of Performance measures |
| Subject | EQR Protocol 6 |
| Author | CMS |
| File Modified | 2012-10-05 |
| File Created | 2012-10-05 |