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TMSIS Dataguide Medicaid.gov
Version 3.28.0

RULE-1634

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 Two Record Type (1 to 1)
File Segment Number COT00002
Data Element Name CLAIM-LINE-RECORD-OT.PROCEDURE-CODE-FLAG • CLAIM-LINE-RECORD-OT.PROCEDURE-CODE
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 has a valid, non-null value for PROCEDURE-CODE, then CLAIM-LINE-RECORD-OT.PROCEDURE-CODE is a valid value specified by CLAIM-LINE-RECORD-OT.PROCEDURE-CODE-FLAG or is a state valid value from 'PROCEDURE-CODE-STATE'. when CLAIM-LINE-RECORD-OT.PROCEDURE-CODE-FLAG is '01', CLAIM-LINE-RECORD-OT.PROCEDURE-CODE should be a valid value in 'CPT'. when CLAIM-LINE-RECORD-OT.PROCEDURE-CODE-FLAG is '02', CLAIM-LINE-RECORD-OT.PROCEDURE-CODE should be a valid value in 'ICD-9-PROCEDURE-CODE'. when CLAIM-LINE-RECORD-OT.PROCEDURE-CODE-FLAG is '06', CLAIM-LINE-RECORD-OT.PROCEDURE-CODE should be a valid value in 'HCPCS'. when CLAIM-LINE-RECORD-OT.PROCEDURE-CODE-FLAG is '07', CLAIM-LINE-RECORD-OT.PROCEDURE-CODE should be a valid value in 'ICD-10-PROCEDURE-CODE'.'
Rule Definition If the procedure code is populated on a non-denied, non-void claim line from an OT file, then the procedure code must be a valid value from the list of procedure code values corresponding to the procedure code flag.
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 has a valid, non-null value for PROCEDURE-CODE