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Tier | 2.0 |
---|---|
Tier Description | Relational error |
Error Category | E2001 |
Error Category Message | Values inconsistently specified (single record type, single record) |
Rule Type | One Record Type (Single Record) |
File Segment Number | CRX00002 |
Data Element Name | CLAIM-HEADER-RECORD-RX.TOT-MEDICARE-COINS-AMT • CLAIM-HEADER-RECORD-RX.TOT-BILLED-AMT |
Validation Logic | 'if CLAIM-HEADER-RECORD-RX.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-HEADER-RECORD-RX has a valid, non-null value for TOT-MEDICARE-COINS-AMT and CLAIM-HEADER-RECORD-RX has a valid, non-null value for TOT-BILLED-AMT and CLAIM-HEADER-RECORD-RX.TOT-MEDICARE-COINS-AMT is greater than zero and CLAIM-HEADER-RECORD-RX.TOT-BILLED-AMT is greater than zero, then CLAIM-HEADER-RECORD-RX.TOT-MEDICARE-COINS-AMT is less than or equal to CLAIM-HEADER-RECORD-RX.TOT-BILLED-AMT' |
Rule Definition | If the total Medicare coinsurance amount and total billed amount are populated and greater than zero on a non-denied claim from an RX file, then the total Medicare coinsurance amount value reported must be less than or equal to the total billed amount value |
Denominator Logic | # of RX claim headers with CLAIM-HEADER-RECORD-RX.CLAIM-STATUS-CATEGORY not equal to 'F2' AND with CLAIM-HEADER-RECORD-RX.TOT-MEDICARE-COINS-AMT equal to a valid, non-null value AND with CLAIM-HEADER-RECORD-RX.TOT-BILLED-AMT equal to a valid, non-null value AND with CLAIM-HEADER-RECORD-RX.TOT-BILLED-AMT greater than zero AND with CLAIM-HEADER-RECORD-RX.TOT-MEDICARE-COINS-AMT greater than zero |