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TMSIS Dataguide Medicaid.gov
Version 3.36.0

RULE-1558

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-HIC-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.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.CROSSOVER-INDICATOR equals '1' and CLAIM-HEADER-RECORD-OT has a null or invalid value for MEDICARE-BENEFICIARY-IDENTIFIER, then CLAIM-HEADER-RECORD-OT has a valid, non-null value for MEDICARE-HIC-NUM'
Rule Definition If a claim is a non-denied, non-void, crossover claim from an OT file, and the medicare beneficiary identifier is not populated, then the medicare hic number is populated.
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.CROSSOVER-INDICATOR equals '1' and with CLAIM-HEADER-RECORD-OT has a null or invalid value for MEDICARE-BENEFICIARY-IDENTIFIER