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TMSIS Dataguide Medicaid.gov
Version 3.27.0

RULE-1540

Validation Rule
Last updated

Tier 3.0
Tier Description Relational error
Error Category E3002
Error Category Message Values inconsistently specified (multiple record types, multi file)
Rule Type Three Record Type Rule
File Segment Number PRV00005
Data Element Name CLAIM-HEADER-RECORD-OT.SUBMITTING-STATE • CLAIM-HEADER-RECORD-OT.BILLING-PROV-NUM
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.TYPE-OF-CLAIM is not equal to one of the following: '2', 'B', 'V' and CLAIM-HEADER-RECORD-OT.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and CLAIM-HEADER-RECORD-OT has a valid, non-null value for BILLING-PROV-NUM, then for every record of type CLAIM-HEADER-RECORD-OT, ((there must be a valid record of type PROV-IDENTIFIERS that matches on the join keys where PROV-IDENTIFIERS.PROV-IDENTIFIER-TYPE equals '1' and (CLAIM-HEADER-RECORD-OT.BEGINNING-DATE-OF-SERVICE >= PROV-IDENTIFIERS.PROV-IDENTIFIER-EFF-DATE and CLAIM-HEADER-RECORD-OT.ENDING-DATE-OF-SERVICE <= PROV-IDENTIFIERS.PROV-IDENTIFIER-END-DATE)) OR (there must be a valid record of type PROV-ATTRIBUTES-MAIN that matches on the join keys and (CLAIM-HEADER-RECORD-OT.BEGINNING-DATE-OF-SERVICE >= PROV-ATTRIBUTES-MAIN.PROV-ATTRIBUTES-EFF-DATE and CLAIM-HEADER-RECORD-OT.ENDING-DATE-OF-SERVICE <= PROV-ATTRIBUTES-MAIN.PROV-ATTRIBUTES-END-DATE)))
Rule Definition If the billing provider number is populated on a non-denied, non-capitated claim from the OT file, then either the billing provider number value reported must be equal to a provider identifier value reported with a provider identifier type value for state-assigned Medicaid provider identifiers on a provider identifiers segment from a PRV file where the effective and end dates of the provider identifiers segment overlap with the beginning date of service and (if populated) ending date of service on the claim OR the billing provider number value reported must be equal to a submitting state provider ID on a provider main attributes segment from a PRV file where the effective and end dates of the provider main attributes segment overlap with the beginning date of service and (if populated) ending date of service on the claim.
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.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and with CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM is not equal to one of the following: '2', 'B', 'V' and with CLAIM-HEADER-RECORD-OT has a valid, non-null value for BILLING-PROV-NUM