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TMSIS Dataguide Medicaid.gov
Version 3.27.0

RULE-1657

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 Three Record Type Rule
File Segment Number ELG00002
Data Element Name CLAIM-LINE-RECORD-OT.TYPE-OF-SERVICE
Validation Logic 'if CLAIM-HEADER-RECORD-OT.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654' and PRIMARY-DEMOGRAPHICS-ELIGIBILITY.SEX equals 'M', then CLAIM-LINE-RECORD-OT.TYPE-OF-SERVICE is not equal to one of the following: '025', '085''
Rule Definition If a non-denied OT claim and a primary demographics eligibility segment has a value populated for sex that equals 'male' then the OT claim line must not have a type of service populated that equals nurse-midwife services for prenatal, pre-pregnancy family planning services.
Denominator Logic # of OT claim lines with CLAIM-HEADER-RECORD-OT.CLAIM-STATUS-CATEGORY not equal to 'F2' and with CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS not in: '26', '87', '542', '585', '654' and with PRIMARY-DEMOGRAPHICS-ELIGIBILITY.SEX equal to 'M'