RULE-1632

Tier	2.1
Tier Description	Relational error
Error Category	E2102
Error Category Message	Values inconsistently specified (multi record, single file)
Rule Type	Three Record Type Rule
File Segment Number	COT00002
Data Element Name	FILE-HEADER-RECORD-OT.END-OF-TIME-PERIOD • CLAIM-LINE-RECORD-OT.ENDING-DATE-OF-SERVICE
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-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654', '686' and CLAIM-LINE-RECORD-OT.TYPE-OF-SERVICE is not equal to one of the following: '119', '120', '121', '122' and CLAIM-LINE-RECORD-OT has a valid, non-null value for ENDING-DATE-OF-SERVICE and FILE-HEADER-RECORD-OT has a valid, non-null value for END-OF-TIME-PERIOD, then CLAIM-LINE-RECORD-OT.ENDING-DATE-OF-SERVICE is less than or equal to FILE-HEADER-RECORD-OT.END-OF-TIME-PERIOD'
Rule Definition	If ending date of service is populated on a non-denied, non-void claim line from an OT file that is not a capitated payment or premium payment and end of time period is populated on the file header, then the ending date of service value reported must be before or equal to the end of time period value reported.
Denominator Logic	# of OT claim lines 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-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654', '686' and with CLAIM-LINE-RECORD-OT.TYPE-OF-SERVICE is not equal to one of the following: '119', '120', '121', '122' and with CLAIM-LINE-RECORD-OT has a valid, non-null value for ENDING-DATE-OF-SERVICE and with FILE-HEADER-RECORD-OT has a valid, non-null value for END-OF-TIME-PERIOD

Tier

2.1

Tier Description

Relational error

Error Category

E2102

Error Category Message

Values inconsistently specified (multi record, single file)

Rule Type

Three Record Type Rule

File Segment Number

COT00002

Data Element Name

FILE-HEADER-RECORD-OT.END-OF-TIME-PERIOD • CLAIM-LINE-RECORD-OT.ENDING-DATE-OF-SERVICE

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-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654', '686' and CLAIM-LINE-RECORD-OT.TYPE-OF-SERVICE is not equal to one of the following: '119', '120', '121', '122' and CLAIM-LINE-RECORD-OT has a valid, non-null value for ENDING-DATE-OF-SERVICE and FILE-HEADER-RECORD-OT has a valid, non-null value for END-OF-TIME-PERIOD, then CLAIM-LINE-RECORD-OT.ENDING-DATE-OF-SERVICE is less than or equal to FILE-HEADER-RECORD-OT.END-OF-TIME-PERIOD'

Rule Definition

If ending date of service is populated on a non-denied, non-void claim line from an OT file that is not a capitated payment or premium payment and end of time period is populated on the file header, then the ending date of service value reported must be before or equal to the end of time period value reported.

Denominator Logic

# of OT claim lines 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-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654', '686' and with CLAIM-LINE-RECORD-OT.TYPE-OF-SERVICE is not equal to one of the following: '119', '120', '121', '122' and with CLAIM-LINE-RECORD-OT has a valid, non-null value for ENDING-DATE-OF-SERVICE and with FILE-HEADER-RECORD-OT has a valid, non-null value for END-OF-TIME-PERIOD

Published Date	Data Guide Version	Validation Rule	Action	Field	Before	After
08/21/2020	2.4.0	RULE-1632	UPDATE	Data Dictionary - Validation Rules	Rule only triggered on adjustment claim lines, not on original claims.	Rules will also be triggered on original claim lines and ADJUSTMENT-IND and LINE-ADJUSTMENT-IND will be used to join claim headers and claim lines for the purpose of applying line-level validation rules. 'if CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654' and CLAIM-LINE-RECORD-OT.TYPE-OF-SERVICE is not equal to one of the following: '119', '120', '121', '122' and CLAIM-LINE-RECORD-OT has a valid, non-null value for ENDING-DATE-OF-SERVICE and FILE-HEADER-RECORD-OT has a valid, non-null value for END-OF-TIME-PERIOD and CLAIM-HEADER-RECORD-OT.CLAIM-STATUS-CATEGORY does not equal 'F2', then CLAIM-LINE-RECORD-OT.ENDING-DATE-OF-SERVICE is less than or equal to FILE-HEADER-RECORD-OT.END-OF-TIME-PERIOD'
05/21/2021	3.0.0	RULE-1632	UPDATE	Data Dictionary - Validation Rules	if CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654' and CLAIM-LINE-RECORD-OT.TYPE-OF-SERVICE is not equal to one of the following: '119', '120', '121', '122' and CLAIM-LINE-RECORD-OT has a valid, non-null value for ENDING-DATE-OF-SERVICE and FILE-HEADER-RECORD-OT has a valid, non-null value for END-OF-TIME-PERIOD and CLAIM-HEADER-RECORD-OT.CLAIM-STATUS-CATEGORY does not equal 'F2', then CLAIM-LINE-RECORD-OT.ENDING-DATE-OF-SERVICE is less than or equal to FILE-HEADER-RECORD-OT.END-OF-TIME-PERIOD'	if and 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 is not equal to '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-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654', '686' and CLAIM-LINE-RECORD-OT.TYPE-OF-SERVICE is not equal to one of the following: '119', '120', '121', '122' and CLAIM-LINE-RECORD-OT has a valid, non-null value for ENDING-DATE-OF-SERVICE and FILE-HEADER-RECORD-OT has a valid, non-null value for END-OF-TIME-PERIOD then CLAIM-LINE-RECORD-OT.ENDING-DATE-OF-SERVICE is less than or equal to FILE-HEADER-RECORD-OT.END-OF-TIME-PERIOD'