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TMSIS Dataguide Medicaid.gov
Version 3.27.0

RULE-1544

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 Two Record Type (1 to 1)
File Segment Number PRV00005
Data Element Name CLAIM-HEADER-RECORD-OT.SUBMITTING-STATE • PROV-IDENTIFIERS.PROV-IDENTIFIER-TYPE • CLAIM-HEADER-RECORD-OT.BILLING-PROV-NPI-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: '3', 'C', 'W' 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 valid, non-null value for BILLING-PROV-NPI-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(PROV-IDENTIFIERS[SUBMITTING-STATE, PROV-IDENTIFIER], CLAIM-HEADER-RECORD-OT[SUBMITTING-STATE, BILLING-PROV-NPI-NUM]), where PROV-IDENTIFIERS.PROV-IDENTIFIER-TYPE equals '2'
Rule Definition If a claim is a non-denied, non-void claim from an OT file, and the billing provider NPI number is populated, then for matching records in provider identifiers, the provider identifier type is equal to 2 (NPI).
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.TYPE-OF-CLAIM is not equal to one of the following: '3', 'C', 'W' 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 BILLING-PROV-NPI-NUM