RULE-1863
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If date prescribed and prescription fill date are populated on a non-denied claim from an RX file, then the date prescribed value reported must be before or equal to the prescription fill date value reported.
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RULE-1867
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If a claim is a non-denied claim from an RX file, then the prescription fill date value reported must be a valid date of the form CCYYMMDD.
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RULE-1869
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If prescription fill date is populated on a non-denied claim from an RX file and end of time period is populated on the file header, then the prescription fill date value reported must be before or equal to the end of time period value reported.
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RULE-1871
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If a claim is a non-denied, non-void claim from an RX file and the primary demographics eligibility segment has a valid value populated for date of death, and the claim header has a valid value populated for prescription fill date, then prescription fill date is less than or equal to the date of death.
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RULE-7197
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If plan ID is populated on a non-denied Medicaid, S-CHIP, or Other encounter from an RX 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 where the prescription fill date on the claim is within the effective and end dates of the managed care participation segment.
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RULE-7201
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If plan ID is populated on a non-denied Medicaid, S-CHIP, or Other encounter from an RX file, then the plan ID must be equal to the plan ID on a managed care main segment from an MCR file where the prescription fill date is within the contract effective and end dates on the managed care main segment.
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RULE-7214
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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 RX file, and is a Medicaid or Medicaid-expansion CHIP FFS, Medicaid or Medicaid-expansion CHIP Encounter, separate CHIP FFS or separate CHIP Encounter claim, then the prescription fill date must be populated.
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RULE-7414
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If a claim in a non-denied, original or adjustment FFS or Encounter crossover claim from an RX file, and the MSIS ID is populated and the prescription fill date 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-7549
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If the 1115A demonstration indicator is equal to 1 (yes) on a non-denied claim from an RX file, and the prescription fill date 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-7718
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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 RX file, and is a Medicaid or Medicaid-expansion CHIP Encounter or separate CHIP Encounter claim, then the claim header prescription fill date must be populated.
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RULE-7773
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If a claim is a non-denied claim from an RX file, and the waiver type is populated, and the claim prescription fill date 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-7809
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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 RX file, and is a Medicaid or Medicaid-expansion CHIP Fee for Service or Separate CHIP Fee for Service claim, then the claim header prescription fill date must be populated.
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RULE-7928
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If the dispensing prescription drug provider number is populated on a non-denied claim from an RX file and the claim is a Medicaid or M-CHIP Encounter or Separate CHIP Encounter original or adjustment paid claim, the claim dispensing prescription drug provider number is equal to the submitting state provider identifier on the provider medicaid enrollment segment with an active provider enrollment status where the prescription fill date is within effective and end dates of the provider medicaid enrollment segment on the pharmacy claim.
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RULE-7936
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If the dispensing prescription drug provider number is populated on a non-denied claim from an RX file and the claim is a Medicaid or M-CHIP FFS or Separate CHIP FFS original or adjustment paid claim, the claim dispensing prescription drug provider number is equal to the submitting state provider identifier on the provider medicaid enrollment segment with an active provider enrollment status where the prescription fill date is within effective and end dates of the provider medicaid enrollment segment on the pharmacy claim.
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RULE-7742
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If a claim in a non-denied, original or adjustment Encounter crossover claim from an RX file, and the MSIS ID is populated and the presription fill date 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-7984
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If a claim in a non-denied, original or adjustment FFS crossover claim from an RX file, and the MSIS ID is populated and the presription fill date 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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