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TMSIS Dataguide Medicaid.gov
Version 3.27.0

RULE-1591

Validation Rule
Last updated

No Updates

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 • CLAIM-HEADER-RECORD-OT.HEALTH-HOME-PROVIDER-NPI • PROV-IDENTIFIERS.PROV-IDENTIFIER-TYPE
Validation Logic if CLAIM-HEADER-RECORD-OT.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-HEADER-RECORD-OT has a valid, non-null value for HEALTH-HOME-PROVIDER-NPI and CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM is not equal to one of the following: '3', 'C', 'W', 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, HEALTH-HOME-PROVIDER-NPI]), where PROV-IDENTIFIERS.PROV-IDENTIFIER-TYPE equals '2'
Rule Definition If a claim is a non-denied claim from an OT file that is not an encounter claim and the home health provider NPI is populated, then the prov identifier type on the provider identifiers segment must be populated with the value '2'.
Denominator Logic # of OT claim headers with CLAIM-HEADER-RECORD-OT.CLAIM-STATUS-CATEGORY not equal to 'F2' and with CLAIM-HEADER-RECORD-OT.HEALTH-HOME-PROVIDER-NPI equal to a valid, non-null value and with CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM not in: '3', 'C', 'W'