RULE-1691

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	ELG00003
Data Element Name	CLAIM-LINE-RECORD-OT.CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT
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.CLAIM-STATUS is not equal to one of the following: '26', '87', '542', '585', '654', '686' and CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM is not equal to one of the following: 'Z', '3', 'C', 'W' and CLAIM-HEADER-RECORD-OT.ADJUSTMENT-IND does not equal '1' and CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654', '686' and VARIABLE-DEMOGRAPHICS-ELIGIBILITY.CHIP-CODE is equal to one of the following: '2', '3', then CLAIM-LINE-RECORD-OT.CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT equals '02''
Rule Definition	If the MSIS ID on a non-denied, non-void claim line from an OT file is equal to the MSIS ID reported with a CHIP code for Medicaid-expansion CHIP or separate XXI CHIP on a variable demographic eligibility segment from an ELG file, then the CMS-64 category for federal reimbursement value reported must be for Title XXI Medicaid funding.
Denominator Logic	# of OT claim lines with CLAIM-HEADER-RECORD-OT.CLAIM-STATUS-CATEGORY not equal to 'F2' and with CLAIM-HEADER-RECORD-OT.CLAIM-DENIED-INDICATOR not equal to '0' and with CLAIM-HEADER-RECORD-OT.CLAIM-STATUS is not equal to one of the following: '26', '87', '542', '585', '654', '686' and with CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM is not equal to one of the following: 'Z', '3', 'C', 'W' and with CLAIM-HEADER-RECORD-OT.ADJUSTMENT-IND is not equal to '1' 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-HEADER-RECORD-OT.SUBMITTING-STATE and CLAIM-HEADER-RECORD-OT.MSIS-IDENTIFICATION-NUM that match VARIABLE-DEMOGRAPHICS-ELIGIBILITY.SUBMITTING-STATE and VARIABLE-DEMOGRAPHICS-ELIGIBILITY.MSIS-IDENTIFICATION-NUM) and with VARIABLE-DEMOGRAPHICS-ELIGIBILITY.CHIP-CODE is equal to one of the following: '2', '3'

Published Date	Data Guide Version	Validation Rule	Action	Field	Before	After
08/21/2020	2.4.0	RULE-1691	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-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.CLAIM-STATUS is not equal to one of the following: '26', '87', '542', '585', '654' and CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM does not equal 'Z' and CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654' and VARIABLE-DEMOGRAPHICS-ELIGIBILITY.CHIP-CODE is equal to one of the following: '2', '3', then CLAIM-LINE-RECORD-OT.CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT equals '02''
09/11/2020	2.4.0	RULE-1691	UPDATE	Data Dictionary - Validation Rules	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.CLAIM-STATUS is not equal to one of the following: '26', '87', '542', '585', '654' and CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM does not equal 'Z' and CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654' and VARIABLE-DEMOGRAPHICS-ELIGIBILITY.CHIP-CODE is equal to one of the following: '2', '3', then CLAIM-LINE-RECORD-OT.CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT equals '02'	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.CLAIM-STATUS is not equal to one of the following: '26', '87', '542', '585', '654' and CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM not in ('Z','3','C','W') and CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654' and VARIABLE-DEMOGRAPHICS-ELIGIBILITY.CHIP-CODE is equal to one of the following: '2', '3', then CLAIM-LINE-RECORD-OT.CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT equals '02'
01/27/2021	3.0.0	RULE-1691	UPDATE	Data Dictionary - Validation Rules	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.CLAIM-STATUS is not equal to one of the following: '26', '87', '542', '585', '654' and CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM is not equal to one of the following: 'Z', '3', 'C', 'W' and CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654' and VARIABLE-DEMOGRAPHICS-ELIGIBILITY.CHIP-CODE is equal to one of the following: '2', '3', then CLAIM-LINE-RECORD-OT.CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT equals '02''	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.CLAIM-STATUS is not equal to one of the following: '26', '87', '542', '585', '654','686' and CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM is not equal to one of the following: 'Z', '3', 'C', 'W' and CLAIM-HEADER-RECORD-OT.ADJUSTMENT-IND is not equal to '1' and CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654','686' and VARIABLE-DEMOGRAPHICS-ELIGIBILITY.CHIP-CODE is equal to one of the following: '2', '3', then CLAIM-LINE-RECORD-OT.CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT equals '02''
03/15/2019	2.3.0	RULE-1691	UPDATE	Data Dictionary - Validation Rules	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 VARIABLE-DEMOGRAPHICS-ELIGIBILITY.CHIP-CODE is equal to one of the following: '0', '1', '2', then CLAIM-LINE-RECORD-OT.CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT equals '02'	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.CLAIM-STATUS does NOT equal to ('26', '87', '542', '585', '654') and CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM does NOT equal 'Z' and CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS does NOT equal ('26', '87', '542', '585', '654') and VARIABLE-DEMOGRAPHICS-ELIGIBILITY.CHIP-CODE is equal to one of the following: '2', '3', then CLAIM-LINE-RECORD-OT.CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT equals '02'