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TMSIS Dataguide Medicaid.gov
Version 3.36.0

RULE-1417

Validation Rule
Last updated

Tier 2.0
Tier Description Relational error
Error Category E2001
Error Category Message Values inconsistently specified (single record type, single record)
Rule Type One Record Type (Single Record)
File Segment Number COT00002
Data Element Name CLAIM-HEADER-RECORD-OT.MEDICARE-COMB-DED-IND
Validation Logic 'if CLAIM-HEADER-RECORD-OT.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-HEADER-RECORD-OT.CROSSOVER-INDICATOR equals '0', then CLAIM-HEADER-RECORD-OT.MEDICARE-COMB-DED-IND equals '0''
Rule Definition If a claim is a non-denied, non-crossover OT claim that is not an encounter claim, then the medicare comb ded indicator must be an amount not combined with the coinsurance amount.
Denominator Logic # of OT claim headers with CLAIM-HEADER-RECORD-OT.CLAIM-STATUS-CATEGORY not equal to 'F2' AND with CLAIM-HEADER-RECORD-OT.CROSSOVER-INDICATOR equals '0' AND with CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM not in '3', 'C', 'W'