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TMSIS Dataguide Medicaid.gov
Version 3.27.0

RULE-1347

Validation Rule
Last updated

Tier 1.1
Tier Description Value Error
Error Category E1102
Error Category Message Value does not match specification
Rule Type One Record Type (Single Record)
File Segment Number COT00002
Data Element Name CLAIM-HEADER-RECORD-OT.DIAGNOSIS-CODE-2 • CLAIM-HEADER-RECORD-OT.DIAGNOSIS-CODE-FLAG-2
Validation Logic 'if CLAIM-HEADER-RECORD-OT.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-HEADER-RECORD-OT.CLAIM-DENIED-INDICATOR does not equal '0' and CLAIM-HEADER-RECORD-OT.ADJUSTMENT-IND does not equal '1' and CLAIM-HEADER-RECORD-OT.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654', '686' and CLAIM-HEADER-RECORD-OT has a non-null value for DIAGNOSIS-CODE-2, then when CLAIM-HEADER-RECORD-OT.DIAGNOSIS-CODE-FLAG-2 is '1', CLAIM-HEADER-RECORD-OT.DIAGNOSIS-CODE-2 should be a valid value in 'ICD-9-DIAGNOSIS-CODE'. when CLAIM-HEADER-RECORD-OT.DIAGNOSIS-CODE-FLAG-2 is '2', CLAIM-HEADER-RECORD-OT.DIAGNOSIS-CODE-2 should be a valid value in 'ICD-10-DIAGNOSIS-CODE'.'
Rule Definition If the second diagnosis code is populated on a non-denied, non-void claim from an OT file, then the value for the second diagnosis code must be a valid value from the list of diagnosis code values corresponding to the second diagnosis code flag.
Denominator Logic # of OT claim headers with CLAIM-HEADER-RECORD-OT.CLAIM-STATUS-CATEGORY does not equal 'F2' and with CLAIM-HEADER-RECORD-OT.CLAIM-DENIED-INDICATOR does not equal '0' and with CLAIM-HEADER-RECORD-OT.ADJUSTMENT-IND is not equal to '1' and with CLAIM-HEADER-RECORD-OT.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654', '686' and with CLAIM-HEADER-RECORD-OT has a valid, non-null value for DIAGNOSIS-CODE-2