RULE-7983
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If a claim in a non-denied, original or adjustment FFS crossover claim from an OT file, and the MSIS ID is populated and the beginning date of service is populated with a date that overlaps with the reported eligibility determinant effective and end dates, and the primary eligibility group indicator is equal to '1', then the dual eligible code is equal to '01', '02', '04', '08'
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RULE-7741
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If a claim in a non-denied, original or adjustment Encounter crossover claim from an OT file, and the MSIS ID is populated and the beginning date of service is populated with a date that overlaps with the reported eligibility determinant effective and end dates, and the primary eligibility group indicator is equal to '1', then the dual eligible code is equal to '01', '02', '04', '08'
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RULE-7392
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If a claim is a non-denied, non-void claim from an OT file, and is a Medicaid/Medicaid-expansion CHIP or S-CHIP service tracking claim and is an original claim or a replacement/resubmission claim payment then the claim header beginning date of service must be populated.
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RULE-7804
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If a claim is on a non-denied claim and is an original claim or a replacement/resubmission claim payment from an OT file, and is a Medicaid or Medicaid-expansion CHIP Fee for Service or Separate CHIP Fee for Service claim, then the claim header beginning date of service must be populated.
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RULE-7772
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If a claim is a non-denied claim from an OT file, and the waiver type is populated, and the claim beginning date of service is between the waiver enrollment effective and end dates, then the claim waiver type is equal to the waiver participation waiver type.
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RULE-7726
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If a claim is a non-denied claim and is an original claim or a replacement/resubmission claim payment from an OT file, and is a Medicaid or Medicaid-expansion CHIP Capitation or separate CHIP Capitation claim, then the claim header beginning date of service must be populated.
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RULE-7722
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If a claim is on a non-denied claim and is an original claim or a replacement/resubmission claim payment from an OT file, and is a Medicaid or Medicaid-expansion CHIP encounter or separate CHIP Encounter claim, then the claim header beginning date of service must be populated.
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RULE-7706
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If plan ID is populated on a non-denied Medicaid, S-CHIP, or Other capitation from an OT file, then the plan ID must be equal to the plan ID on a managed care participation segment from an ELG file with the same MSIS ID and effective and end dates that overlap the beginning date of service.
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RULE-7702
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If plan ID is populated on a non-denied Medicaid, S-CHIP, or Other capitation from an OT file, then the plan ID must be equal to the plan ID on a managed care main segment from an MCR file where the beginning date of service on the claim is within the contract effective and end dates on the managed care main segment.
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RULE-7552
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If the 1115A demonstration indicator is equal to 1 (yes) on a non-denied claim from an OT file, and the beginning date of service is within the 1115A effective and end dates, then the 1115A demonstration indicator value reported on the 1115A demonstration information segment must be populated with a 1 value.
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RULE-7424
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If a claim in a non-denied, original or adjustment FFS or Encounter crossover claim from an OT file, and the MSIS ID is populated and the beginning date of service is populated with a date that overlaps with the reported eligibility determinant effective and end dates, and the primary eligibility group indicator is equal to '1', then the dual eligible code is equal to '01', '02', '04', '08'
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RULE-1352
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If a claim is a non-denied claim from an OT file, then the beginning date of service value reported must be a valid date of the form CCYYMMDD.
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RULE-7215
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If a claim is a non-denied claim and is an original claim or a replacement/resubmission claim payment from an OT file, and is a Medicaid or Medicaid-expansion CHIP, Medicaid or Medicaid-expansion CHIP encounter, separate CHIP FFS or encounter claim or CHIP capitated or separate CHIP capitated payment, then the beginning date of service must be populated.
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RULE-7200
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If plan ID is populated on a non-denied Medicaid, S-CHIP, or Other encounter from an OT file, then the plan ID must be equal to the plan ID on a managed care main segment from an MCR file where the beginning date of service on the claim is within the contract effective and end dates on the managed care main segment.
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RULE-7196
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If plan ID is populated on a non-denied, non-void Medicaid, S-CHIP, or Other encounter from an OT file, then the plan ID must be equal to the plan ID on a managed care participation segment from an ELG file with the same MSIS ID and enrollment effective and end dates that overlap the beginning date of service.
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RULE-1357
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If a non-denied OT claim has a value populated for beginning date of service and the date of death is populated on the primary demographics eligibility segment, then the claim beginning date of service must be less than or equal to the date of death.
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RULE-1356
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If adjudication date and beginning date of service are populated on a non-denied claim from an OT file that is not a Medicaid or Medicaid-expansion, S-CHIP, or Other Capitated Payment, then the beginning date of service value reported must be before or equal to the adjudication date value reported.
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RULE-1355
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If the beginning date of service and ending date of service are populated on a non-denied claim from an OT file, then the beginning date of service value reported must be before the ending date of service value reported.
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RULE-1354
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If beginning date of service is populated on a non-denied claim from an OT file that is not a Medicaid or Medicaid-expansion, S-CHIP, or Other Capitated Payment and end of time period is populated on the file header, then the beginning date of service value reported must be before or equal to the end of time period value reported.
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